Ear Piercing Intake Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone#
*
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
Emergency Contact Name
Phone#
Format: (000) 000-0000.
How did you hear about us?
Is the person being pierced today over 18?
*
Yes
No
If under 18, Parent/Legal Guardian full name, relationship, phone number
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Medical History
Do you have any known allergies or sensitivities to metals, including nickel, gold, titanium, stainless steel, or other jewelry?
*
Yes
No
Do you have any allergy or sensitivity to latex, adhesives, antiseptics, soaps, or cleaning products?
*
Yes
No
Have you ever had an allergic reaction to earrings or other jewelry?
*
Yes
No
Have you ever developed a keloid scar or raised/thickened scar?
*
Yes
No
Do you or an immediate family member have a history or keloid scarring?
*
Yes
No
Do you currently have any rash, infection, wound, irritation, cyst, swelling, sunburn, or skin condition on or around the ears?
*
Yes
No
Do you currently have an ear infection or other active infections?
*
Yes
No
Do you have a bleeding or clotting disorder?
*
Yes
No
Do you bruise or bleed excessively?
*
Yes
No
Are you currently taking blood-thinning/anticoagulant medication or other medication that may increase bleeding?
*
Yes
No
Do you have diabetes or another condition that may affect healing or wound healing?
*
Yes
No
Do you have a condition or take medication that suppresses your immune system?
*
Yes
No
Are you undergoing chemotherapy, radiation, or other treatment that may impair healing?
*
Yes
No
Have you had previous problems healing a piercing?
*
Yes
No
Have you ever fainted, become dizzy, or had a severe reaction during a piercing, injection, blood draw, or similar procedure?
*
Yes
No
Have you consumed alcohol or recreational drugs today, or are you otherwise impaired and unable to provide informed consent?
*
Yes
No
Is there any other medical condition, medication, allergy, or health concern that the piercer should know about before performing the procedure?
*
Yes
No
Notes:
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Consent Form
I hereby consent to and authorize Lancaster’s Luxe Lashes to perform ear piercing.
*
I voluntarily consent to the ear-piercing procedure described above.
I understand that piercing creates an opening in the skin and that risks can include pain, tenderness, bleeding, bruising, swelling, redness, infection, scarring, keloid formation, allergic reaction, embedding of jewelry, migration/rejection, asymmetry, and unsatisfactory cosmetic results.
I understand that exact symmetry cannot be guaranteed because ears are naturally different in shape and position.
I have reviewed and approved the proposed piercing placement before the piercing is performed.
I understand that touching, twisting, prematurely removing/changing jewelry, improper cleaning, swimming/submersion, pressure or trauma to the piercing may interfere with healing.
I understand that healing times vary and that the piercing may appear healed externally before the internal piercing channel is completely healed.
I agree to follow the written aftercare instructions provided to me.
I understand that I should seek appropriate medical care if I develop signs of a serious infection, severe swelling, spreading redness, fever, significant drainage, an embedded earring, or another concerning reaction.
I have disclosed relevant medical conditions, medications, allergies, and previous reactions to the best of my knowledge.
I have had the opportunity to ask questions and have received answers I understand.
I understand that the piercer cannot guarantee how my body will heal or the final result.
By signing below, I acknowledge there is a no-refund policy in place. By paying for my service at the completion, I am acknowledging that I am satisfied with my services provided and credit card disputes will then be considered frivolous.
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
For Minors
I certify that I am the parent or legal guardian of the minor named above and have legal authority to consent to this procedure. I authorize Lancaster’s Luxe Lashes & Spa LLC and its authorized piercer to perform the ear piercing described on this form. I have reviewed the risks, aftercare requirements, jewelry selection and proposed placement and consent to the procedure.
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Take Photo
*
Name Printed
*
Signature
*
Submit
Geolocation
*
Should be Empty: