Body Suspension Informed Consent Form

This information we are giving you about body suspension is designed to help you make an informed decision about having one performed on you.  It is in no way meant to scare, deter or encourage your decision.
Known health concerns include but are not limited to the following: short and/or long term pain, potential for infection, intolerance/reaction to certain metals, tearing of tissue, scarring, numbness, bruising, bleeding, vomiting, loss of consciousness and many different forms of shock. 

*** The state of shock is a potentially life threatening condition ***

Having read this I, ________________________, understand that there are inherent and potential undetermined risks involved with body suspension.  I am of sound mind and body and with this knowledge of the above information do freely choose to suspend in a _________________________ position / style on this ______ day of ___________ 20___.  I also claim to be completely sober and free of any infections, viruses, diseases or medical conditions which may adversely affect my physical capacity to be pierced or cause harm to others.
To ensure proper healing, I agree to follow the suggested procedures given verbally until healing is complete.  I understand that healing may take up to two to four weeks, or longer to heal.
To induce the body suspension team to pierce/stretch and suspend my body, and in consideration of their doing so, I hereby release and hold harmless, The RISE Suspension Team and any employees or associates thereof from all manner of liabilities, claims and demands, in law and equity which I or my heirs have or might have now or hereafter by reason of my request to be pierced or stretched.

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Signature
	
I am under the care of a physician for __________________________________________
I am taking the following medications______________________________________ 
I have a history of allergies to ____________________________________________ 
How much alcohol did you drink in the last 24 hours?  _______________________
Phone #: _____________________Email: ___________________________________

History of fainting			yes	no 
History of bleeding disorders	yes	no 
Heart Condition or Epilepsy	yes	no 
Hypoglycemia or Diabetes	yes	no 

Age: _________