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Piercing Consent Form
Client Information
Name
*
First Name
Last Name
Pronouns
He/him
She/her
They/them
Other
Phone Number
*
Email
*
example@baronart.tattoo
Birthdate
*
/
Month
/
Day
Year
I am 18+ years old
*
Yes
No
Attach a copy of your legal ID (military ID cannot be accepted.)
*
Client ID
Drag and drop files here
Choose a file
I am the person on the legal ID presented as proof that I am at least 18 years of age or I am with a legal guardian.
Cancel
of
Attach a copy of the guardian's legal ID (military ID cannot be accepted)
*
Guardian ID
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Choose a file
Consenting legal guardian is present and is the person on the legal ID presented.
Cancel
of
Attach a copy of the minor's birth certificate or proof of guardianship.
*
Proof of Guardianship
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Choose a file
Names on documentation must match attached IDs.
Cancel
of
Pre-Procedure Questionnaire
Do you have any conditions/communicable diseases or take any medications that may affect the body art procedure or healing process?
*
Do you have any history of herpes infection, diabetes, allergic reaction to latex or antibiotics, hemophilia, or other bleeding disorder or cardiac valve disease?
*
Yes
No
Have you taken antibiotics within the past two weeks?
*
Yes
No
Do you have any medical conditions/communicable diseases?
*
Asthma
Blood thinners
Diabetes
Eczema/Psoriasis
Epilepsy
Faintness or dizzy spells
Heart condition
Hemophilia
Hepatitis
Herpes
HIV
Infections
Pregnant/Nursing
Prophylactic antibiotics
Rashes
Scarring/Keloiding
None
Other
Do you take any medications?
*
Yes
No
Please list medications.
Are you currently under a doctor's care for a continuing condition?
*
Yes
No
Do you have any conditions that may affect the application or healing of the body piercing?
*
Yes
No
Please list conditions.
Are you prone to fainting?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
Are you prone to heavy bleeding or have you taken aspirin, ibuprofen, or blood thinners with the last 24 hours?
*
Yes
No
Have you consumed any food within the last 2 hours? We recommend staying nourished to sustain your energy. Please let your body artist know if you would like to take a break.
*
Yes
No
Acknowledgment and Waiver
Please check all boxes below to agree.
*
I am not under the influence of alcohol or drugs and I am voluntarily submitting to be pierced without duress or coercion.
*
I understand the risks of body art including but not limited to infection, scaring, rejection, difficulties in detecting melanoma, potential need for surgical removal of jewelry and allergic reactions to jewelry metals, latex gloves, and antiseptics.
*
I understand there is possibility of allergic reaction to jewelry inserted into a fresh body piercing.
*
I understand that choosing surgical steel jewelry over titanium or higher grade jewelry carries a higher risk of allergic reaction.
*
I understand that body piercing can result in nerve damage, bone and tooth loss, and that if I remove my jewelry, permanent holes or scars may remain.
*
I agree to immediately notify the body artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure.
*
I understand that if I take out the applied jewelry myself I have full responsibility if my body piercing becomes closed or infected.
*
I agree to follow all instructions concerning the care of my body piercing and if any issues arise I will consult with a piercing artist and/or doctor.
*
I understand that refunds are not offered for services rendered.
*
I understand that jewelry that has been worn cannot be exchanged or refunded.
*
All questions about the body art procedure have been answered to my satisfaction.
*
I indemnify and hold harmless Baron Art Tattoo and its employees against any claims, expenses, damages, and liabilities.
*
I wish to proceed with this body art procedure and I assume any and all risks that may arise from this body art procedure.
*
I acknowledge should any part of this document be construed as illegal then that part shall be void and the rest shall be held in force as if that part did not exist.
*
I certify under penalty of perjury that the above information is true and correct.
Client Signature
*
I have read and agree to the above consent form.
Guardian Signature
*
I have read and agree to the above consent form.
Submit
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