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 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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