Minor Piercing Consent

Legal Name* This field is required.

First Name

Last Name

Preferred NameIf different

First Name

Last Name

Birthdate* This field is required.

Date

Legal Guardian Name* This field is required.

First Name

Last Name

Phone Number* This field is required.

Please enter a valid phone number.

Do you have any of the following medical conditions?* This field is required.Check ALL that apply

HIV

Hepatitis

Herpes

Diabetes

Asthma

Epilepsy

Skin conditions

Blood Thinners

Hemophilia

Eczema/Psoriasis

Heart Conditions

Gonorrhea

Syphilis

Latex Allergies

MRSA/ Staph

Pregnant/Nursing

Fainting/Dizziness

Scarring/Keloiding

Antibiotic Allergies

NONE OF THESE

Other

Do you have a history of herpes at the procedure site?* This field is required.

YESNO

Do you have any cardiac valve disease?* This field is required.

YESNO

Do you have any other risks for blood borne pathogens exposure?* This field is required.ie- working in the medical field etc.

Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol?* This field is required.

Do you use any medications that might affect the healing of the body art you wish to receive?* This field is required.

Do you have a history of medication use or are you currently using medication, including being prescribed antibiotics prior to dental or surgical procedures?* This field is required.

Is there any information that you feel you should provide to the body art practitioner?* This field is required.

In consideration of receiving BODY ART from the practitioner at VELVET ORANGE BODYCRAFT (together with its employees, it’s apprentices, and agents, the “Body Art Business”) I confirm the following by initialing each applicable item:* This field is required.I am under the age of 18 years old and have the presence of my parent or guardian to receive the body piercing.

Clear

* This field is required.I am not under the influence of alcohol or drugs and that I am voluntarily submitting myself to receive body art without duress or coercion.

Clear

* This field is required.I acknowledge that the information that I have provided in the medical questionnaire is complete and true to the best of my knowledge.

Clear

* This field is required.I understand the permanent nature of receiving body art and that removal can be expensive and may leave scars on the procedure site.

Clear

* This field is required.The body art described or shown on the client record form is correctly placed to my specifications.

Clear

* This field is required.All questions about the body art procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the procedure I am about to receive.

Clear

* This field is required.I understand there are restrictions on physical activities such as bathing, recreational water activities, gardening, and contact with animals for 6 weeks

Clear

* This field is required.I understand that any medical information obtained will be subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA).

Clear

* This field is required.I am aware of the signs and symptoms of infection, including, but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site.

Clear

* This field is required.I understand there is a possibility of getting an infection as a result of receiving body art particularly in the event that I do not take proper care of the procedure site.

Clear

* This field is required.I will seek professional medical attention if signs and symptoms of infection occur.

Clear

* This field is required.I agree to follow all instructions concerning the care of my tattoo or piercing, and that any touch-ups needed due to my own negligence will be done at my own expense.

Clear

* This field is required.I understand that there is a chance I might feel lightheaded, dizzy during or after being tattooed or pierced.

Clear

* This field is required.I agree to immediately notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.

Clear

* This field is required. I understand that physical distancing will not be possible during this procedure and that by undergoing this procedure I may increase my risk of contracting pathogens including but not limited to COVID-19.

Clear

* This field is required.I understand that body piercing can result in nerve damage, bone and tooth loss, and that if I choose to remove my jewelry, permanent holes or scars may be left.

Clear

* This field is required.I understand that all piercings pose risks including but not limited to; infection, migration, stretching, tearing and/or rejection.

Clear

* This field is required.I understand there is a possibility of an allergic reaction to the jewelry inserted into the fresh body piercing.

Clear

I; the CLIENT have been fully informed of the risks of body art including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with a body art procedure, I still wish to proceed with the body art application and I assume any and all risks that may arise from body art.* This field is required.

Clear

I; the Legal Guardian have been fully informed of the risks of body art including but not limited to infection, scarring, difficulties in detecting melanoma, and allergic reactions to tattoo pigment, latex gloves, and antibiotics. Having been informed of the potential risks associated with a body art procedure, I still wish to proceed with the body art application and I assume any and all risks that may arise from body art.* This field is required.

Clear

I have received Aftercare Instructions* This field is required.

Clear

Today’s Date

Date

Practitioner* This field is required.

Identification

ID/DL

Birth Certificate

Passport

Tribal ID

Other

Piercing Type* This field is required.

Ear

Body

Mouth

Nose

Piercing Description * This field is required.

Jewelry Quantity* This field is required.

Gauge* This field is required.

Other

Length* This field is required.

Material* This field is required.

Titanium

Gold

Niobium

Other

Jewelry Description* This field is required.

To the best of my knowledge this information is correct * This field is required.

Clear

Needle Packets* This field is required.

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