Body Piercing Consent Form
Please ensure you fill out all fields honestly and accurately. Completion of this form grants permission for Maneia to carry out the requested piercing and does not hold Maneia responsible for any inaccurate or false information given.
Name
First Name
Last Name
Email
example@example.com
Phone Number*
-
Area Code
Phone Number
Date Of Birth
*
/
Day
/
Month
Year
Date
I confirm that I am not taking any blood thinning medication or suffering from any other illness or condition which may affect my body piercing, or my body piercer needs to be aware of. I confirm I am not pregnant or nursing. I understand that a new piercing is susceptible to infection and that proper aftercare of the piercing is my responsibility. I confirm that I have had the aftercare procedure explained to me and that I understand it. I also confirm that I will follow the aftercare procedure until the healing process is complete. I understand that choosing not to purchase aftercare, whilst not withstanding the hygienic conditions of sterile instruments, jewellery and techniques used by GlamStop, there are associated risks with piercings which include scarring, allergic reactions, localised swelling, jewellery embedding and that the piercing may grow out. In giving this consent I release the piercing establishment and its employees from all liabilities, actions and demands which I may have now or in the future for any loss or damage suffered howsoever caused as a result of my piercing (except as a result of fraudulent misstatement) or in respect of personal injury caused by ourselves, negligence and any failure on my part to follow he aftercare procedures. I understand that lying about my age is an offence and my parent/guardian will be held responsible.
Please state chosen piercings here:
Additional Notes (Please input parental consent info here if giving permission for someone under 16 years old)
Are you currently pregnant or nursing?
Yes
No
Have you eaten and slept well?
Yes
No
Have you consumed any drugs or alcohol in the past 24hrs?
Yes
No
Do you knowingly carry HIV or any other blood born viruses?
Yes
No
Do you suffer from epilepsy?
Yes
No
Are you taking any blood thinning medication?
Yes
No
Do you have diabetes or high blood pressure?
Yes
No
Are you allergic to latex?
Yes
No
Are you allergic to plasters?
Yes
No
All body piercings are susceptible to swelling, bleeding, bruising, rection etc. Please confirm you understand the post-indications of your chosen body piercing(s)
Yes
I understand it is my duty to take care of my piercing, to talk to my piercer should I have any concerns and my piercer is not liable once I have left the premises on which my piercing was performed
Yes
Signature
Submit
Should be Empty: