JEWELRY PURCHASE AND CHANGE CONSENT

JEWELRY PURCHASE AND CHANGE CONSENT
I, Client First Name* Last Name* agree that I am purchasing jewelry and allowing Pushing Inc. to change my Piercing to be changed on appointment Date by Piercers Name* and if this jewelry was not purchased from Pushing Inc. Tattoo Emporium they are not held liable or responsible of any reaction or negative effect said jewelry may have.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
AGE *
DATE OF BIRTH *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email
example@example.com
Would you like to receive our email Newsletter? *

YES NO
Signature *

Clear
Date *

Month Day Year
Date
Piercing:Piercing
Jewelry Size: Jewelry Size
Jewelry Material: Jewelry Material
Check-Up Date:Check-Up date
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