Gypsy Stables - Piercing consent form

Piercing consent form

Please fill in all sections
I First Name* hereby declare that I give * full consent to pierce my * and that all the information given is true to my knowledge.
Please SELECT to indicate if you suffer from any of the following
Any heart condition
Seizures
Haemophilia
Any heart condition
Compound immune system eg HIV/Hepatitis
High blood pressure
Any skin conditions eg Psoriasis
Prone to fainting/dizziness
Taking any blood thinning medications eg aspirin/warfarin
Please SELECT to indicate your answer
I am pregnant/ breastfeeding*

YesNo
I am under the influence of alcohol or drugs*

YesNo
I have requested this piercing of my own free will*

YesNo
I am over the age of 16 years*

YesNo
GENITAL PIERCINGS: I am over the age of 18 years

YesNo
Please SELECT to indicate your answer
I understand that the piercing will be carried out under hygienic conditions using sterile instruments and jewellery and pre-sterilised single use needles and that no form of anaesthetic will be used in the procedure. I understand that a new piercing is susceptible to infection until healed and that proper aftercare of the piercing is my responsibility once I leave the studio. I will follow the aftercare procedure as explained verbally and given to me in writing. I understand that not all persons can be pierced and that some piercing may reject or grow out and that associated risks include septicaemia, scarring, allergic reactions, localised swelling trauma and jewellery embedding.*

YesNo
Name*

First NameLast Name
Date of birth*

MonthDayYear
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
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Your signature*

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Piercer Signature - Please let the piercer review the information and sign before submiting the form*

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Piercing consent form

Please SELECT to indicate if you suffer from any of the following

Please SELECT to indicate your answer

Please SELECT to indicate your answer