Body Piercing Consent Form

Body Piercing Consent Form

In order to properly screen for COVID-19 symptoms, this consent form must be completed WITHIN 24 HOURS of your appointment. Your body art practitioner or one of our Guest Experience Experts may contact you for any further information needed.

To complete the consent form you will need :
1. 5-15 minutes of time
2. Your government issued ID (you will take a picture of it in this form). Acceptable forms of identification include a drivers license, passport, permit or temporary ID (only if in good condition). If you are unsure of whether or not your ID is acceptable, please call Superficial at 781.803.3160 and one of our Guest Experience Experts will assist you. * We recommend using a SMART PHONE to complete this form!
If at any point you need to pause filling this form out, click the button on the bottom of the screen to "Save your progress and finish later."

If you are unable to complete this form online, please call Superficial ModSpa at 781.803.3160 so we can make arrangements.

Legal Name *
Preferred Name/Pronouns
Date of Birth *

Month Day Year
Cell Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email Address *
Would you like to sign up for our VIP eNewsletter? *

Yes No I already am a VIP member
Contact-Free Identification

Using the camera on your phone, take a picture of your government issued ID. We accept drivers licenses, state identification cards, permits, and passports. *If you do not have any of these listed or are unsure of whether or not your form of identification will be accepted, please contact Superficial ModSpa ahead of time at 781°803°3160 or superficialmodspa@icloud.com, and one of our Guest Experience Experts will assist you. PLEASE MAKE SURE THE PICTURE YOU TAKE AND SUBMIT IS CLEAR AND LEGIBLE! If necessary, we can still make a copy of your Photo ID at the studio, so please make sure you bring your ID to your appointment for verification, particularly if you experience difficulty with this photo function.
PHOTO OF GOVERNMENT ISSUED IDENTIFICATION. *
I am the person stated on this consent form, and on the legal ID shown above as proof that I am at least 18 years of age. To my knowledge I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing procedure done at this time. *

I agree
Preferences

If your scheduled appointment is for a piercing procedure or jewelry change, please use the space below to describe what kind/s of jewelry you may be interested in. This information will help our licensed Piercing Artists & Guest Experience Experts curate the best items for you to choose from.
Please describe any preferences for you may have for metals, colors, gems, opals, natural stones, etc.

COVID-19 Precautions

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact.
I understand Superficial ModSpa is taking great lengths to protect the public from the pandemic. I understand this is an elective service and I will not hold Superficial ModSpa LLC, any of its contractors or employees liable for possible transmission of COVID-19. *

I agree.
I confirm that I am not presenting any of the symptoms of COVID-19 including (but not limited to) dry cough, running nose, sore throat, shortness of breath, loss of sense of taste or smell, or fever. *

I agree
Do you believe or know that you have come into contact with someone experiencing symptoms of, or has been diagnosed with COVID-19? *

Yes No
I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. I verify that I have not traveled outside of or domestically within the USA in the past 14 days. *

I agree
To prevent the spread of contagious viruses and to help protect others, I understand that I will have to follow Superficial ModSpa’s guidelines. These guidelines can be found on SuperficialModSpa.com, and can be changed at any time as new information and technology become available. *

I agree
I understand that Superficial ModSpa is requiring a mask to be worn upon arrival to my appointment, & it is at the practitioners discretion as to whether or not I can remove my mask. *

I agree
In order to continue to provide you with the high quality piercing experience found exclusively at Superficial ModSpa, the studio has implemented a $10 preparation fee for all appointments which will be paid in studio at your appointment. This fee is non-refundable and will be required for all appointments at Superficial ModSpa. This preparation fee ensures we can provide the time and materials necessary to uphold the proper sanitization and sterilization techniques that keep our staff and clients safe and healthy as we re-enter the Post-COVID-19 world. *

I agree

Contact-Free Identification

Preferences

Medical History

In order to provide you with the best experience,

COVID-19 Precautions

The Final Page