Piercing Consent Form

Book your appointment here:
Piercing Consent Form
I voluntarily give my full consent to body piercings carried out by the practitioner. I am informed about possible side effects and complications of body piercing procedures such as infection and swelling. I understand and agree that it is my responsibility to read and follow the instructions about procedures and aftercare.

I confirm that the information that I provide in this consent form is complete and accurate.
Please acknowledge the following items: *

I do not have symptoms of COVID-19 and accept to follow the rules of the shop during my appointment. I have not contacted to anyone who may have symptoms of COVID-19 or get infected by the virus within 14 days. I understand that I am responsible for the any touch-up work due to my fault, negligence or carelessness. I understand that there is a possibility to get an infection if I will not follow the instructions. I accept that having a piercing services is my voluntary choice. I inform that I am not under the influence of drugs or alcohol during the procedure. I understand that the procedure causes a permanent change to my skin and body. I do not have any mental or medical disability that may affect my wellbeing as a result of having piercing procedure. I release the shop, its administrators, practitioners, stakeholders and workers from any and all of the claims, expenses, liabilities and damages.
Client Information
Client Name *

First Name Last Name
Adress *

Street and housenumber

Straat en Huisnummer 2e regel

Place State/Province

Postcode Country
Date of Birth *

Day Month Year
Date
Phone Number

Area Code Phone Number
Email *
example@example.com
Please select the conditions you have:

Anxiety Eczama Epilepsy Haemophilia Heart Condition HIV Ink Allergy Latex Allergy Nickel Allergy Pregnancy Tuberculosis Other
Are you younger then 16? *

Yes No
If your under 16 you need to bring a parent or caretaker to give permission, who will you bring?
Is there anything else we should know?
Signature, if under 16 signed by a parent or caretaker! *

Clear
Signed Date *

Month Day Year
Date
Nieuwsbrief

Yes, subscribe me to this newsletter.
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Piercing Consent Form

Client Information