Procedure Consent Form

Coin Slot and Large Gauge Consultation Form
Please do not complete this form if you have not read over website information in full.

You are Legally required to have read all information prior to agreeing to the bellow questions. Do not select yes if you have no read over the information
Yes, I have read this information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Age*
Occupation*
Coin Slot PiercingLarge Gauge Piercing
Where would you like your coin slot?*
What area of the body? eg; Helix, conch, forward helix etc
Where would you like your large gauge piercing?*
What area of the body? eg; Helix, conch, forward helix etc
Do you, or have you had piercings in this location?*
Do you have an ideal size in mind?*
Have you thought about what jewellery you might like to wear, or have you seen something that inspires you?*
Please include clearly taken photos of the area in which you would like the coin slot, and if possible, mark the location and size that you have in mind. **

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Please include clearly taken photos of the area in which you would like the large gauge piercing, and if possible, mark the location and size that you have in mind. **

Browse Files

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Do you smoke? If yes, how many per day?*
How often do you consume alcohol?*
Do you have any allergies?*
AsthmaDiabetesEpilepsyCold SoresBacterial InfectionBlood ClotsThyroid DiseaseHeart ProblemsImmune DisordersBad ScarringCancerViral InfectionsHIV/AIDsHigh or Low Blood PressureBleeding DisordersHepatitis B or CPsychiatric TreatmentNone of the above
Please list any past or present medical problems or conditions*
YesNo
If yes, were there any complications with the anaesthetic or infections?*
YesNo
Did you have any complications with this procedure including infection or a reaction the the Anaesthetic? If yes please list*
Are you currently taking any prescription or non-prescription medications? Including supplements and herbal? If yes, please specify.*
YesNo
Do you exercise regularly? If yes, what type of exercise?*
250mL500mL750mL1L1.5L2L2L+
Do you consume caffeine on a regular basis? If yes, how much/how often?*
When was the last time that you had a blood test to check health?*
Were there any issues with Vitamin D and/or B12? If no, have you ever had issues with these vitamins?*
Please list any further key information regarding your chosen procedure.*
Please list what days of the week and what times are most suitable for your phone consultation and please list any questions you would like to discuss as part of your consultation*
I First Name Last Name herby declare the above information I have provided to be accurate and true.
Signature
Once you have submitted this form with all of the information required, we will assess the information required to determine your suitability for your chosen procedure. We will then contact you via email with the next steps on booking your phone consultation.
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Coin Slot and Large Gauge Consultation Form