Name *

First Name

Last Name

Phone

(###)

###

####

Question 1 *

Are you allergic to metals or have you experienced reactions to jewelry in the past (e.g., rashes, irritation, or swelling)?

No

Yes

Question 2 *

Do you have any skin conditions (e.g., eczema, psoriasis, or dermatitis) that could affect the area where the jewelry will be welded?

No

Yes

Question 3 *

Do you currently have any skin infections, cuts, or abrasions in the area where the jewelry will be placed?

No

Yes

Question 4 *

Do you currently have any skin infections, cuts, or abrasions in the area where the jewelry will be placed?

No

Yes

Acknowledgement 1 *

I understand that if I answered "Yes" to any of the questions above, I acknowledge that "Locked In" is not responsible for any adverse reactions or complications resulting from the installation process due to my health conditions

Yes

Acknowledgement 2 *

I understand that if I answered "Yes" to any of the questions above, I acknowledge that "Locked In" is not responsible for any adverse reactions or complications resulting from the installation process due to my health conditions

Yes

Acknowledgement 3 *

I understand that the jewelry I am receiving is permanently welded onto my body. This means that removal requires special tools and may not be easily removed without professional assistance.

Yes

Acknowledgement 4 *

I am aware that my jewelry is made from 14k gold-filled material. While durable, I understand that gold-filled jewelry is subject to tarnishing if repeatedly exposed to chemicals, lotions, perfumes, or other substances.

Yes

Acknowledgement 5 *

I understand that the jewelry may come off if it becomes snagged or pulled. I will exercise caution to avoid situations where my jewelry could be caught.

Yes

Acknowledgement 6 *

If for any reason my jewelry comes off or requires a reweld, I understand that I must retain my receipt to receive the rewelding service.

Yes

Acknowledgement 7 *

I acknowledge that I have provided accurate health information to ensure the procedure is safe for me, and I agree to release Locked In from any liability related to this process.

Yes

Acknowledgement 8 *

I acknowledge that I am fully committed to the purchase and service, and no refunds will be issued for any reason after the jewelry has been welded.

Yes

Acknowledgement 9 *

By signing this form, I give my informed consent to participate in the Locked In permanent jewelry experience, acknowledging that I have read and understood the details provided above.

Yes