Sincerely Pierced

Piercing Consent Form

@brookes.piercings
PLEASE CHECK THE BOXES PROVIDED AFTER READING TO SHOW THAT YOU UNDERSTAND EACH PROVISION. FEEL FREE TO ASK ANY QUESTIONS REGARDING THIS WAIVER.

I acknowledge by signing this Release I have been given the full opportunity to ask any and all questions which I might have about obtaining a piercing from Sincerely Pierced. (hereinafter known as the “Piercer”) and all my questions have been answered to my full and total satisfaction. If you have health or medical concerns, please consult a physician before engaging in a body art procedure. I acknowledge I have been advised of the matters set forth below and I agree as follows:
Please acknowledge the following items:
Client Information
Client Name

First NameLast Name
Signature
Today's Date:

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Please list the placements of piercings you are receiving today:
Age:
Drivers License #:
State:
Exp:
If any of the below answers are 'Yes,' please notify your piercer BEFORE your piercing
Have you ingested anticoagulants, anti-platelet drugs, or NSAIDS (aspirin, ibuprofen, naproxen, etc.) in the last 24 hours?
Have you ingested any medication that may inhibit the ability to heal a skin wound?
Do you have a history of skin diseases, skin lesions, or other skin sensitivities to soaps or disinfectants that might inhibit the healing of the body art procedure?
Do you have hemophilia, epilepsy, a history of seizure, fainting or narcolepsy, or other conditions that may interfere with the body art procedure? Please inform your piercer if so.
Do you have any communicable diseases (Hep A, Hep B, HIV, or any other disease that can be transmitted through broken skin or mucous membranes during the procedure)?
Do you have diabetes, high blood pressure, heart condition, heart disease, or any other conditions that may interfere with the body art procedure?
Should be Empty:

Piercing Consent Form

Client Information

If any of the below answers are 'Yes,' please notify your piercer BEFORE your piercing