Name *

Please list the name of the person receiving permanent jewelry.

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

Must be 13 or older to receive permanent jewelry

MM

DD

YYYY

Do you have any of the following? *

Pacemaker

Allergy/Sensitivity to metal

Any other condition that would make this permanent jewelry experience unsafe?

None of the above

Today's Date *

MM

DD

YYYY

Release and Waiver of Liability *

All of my questions regarding permanent jewelry have been answered by Synergy Jewelry LLC to my satisfaction. I understand that all Synergy Jewelry LLC jewelry is final sale. I understand that this jewelry can break and/or stretch if pulled or caught. I understand that this permanent jewelry can easily be removed. I understand how to take proper care of my permanent jewelry. I understand that if anything happens to my jewelry within the first two weeks, Synergy Jewelry LLC will fix or replace it complimentary at their next pop-up. I understand that Synergy Jewelry LLC guarantees the weld but not the chain or jewelry itself. I acknowledge that I do not have a pacemaker, a sensitivity or allergy to any metals, or have any other condition that might make this permanent jewelry experience unsafe. By signing this form, I acknowledge and accept that Synergy Jewelry LLC is not liable for any medical condition or injury caused by this experience or jewelry. I grant Synergy Jewelry LLC permission to capture images and likeness in photographs, videotapes, and/or digital media. A parent/guardian signature is required if under the age of 18.

Yes, I agree and acknowledge the release and waiver of liability