Health declaration form

In order for us to perform your piercing in the best way and ensure the best healing process, we would like to ask you the following questions.
Have you consumed alcohol, taken drugs, or any other medication in the last 24 hours?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Do you faint easily?*

YesNo
Are you allergic to rubber or latex?*

YesNo
Do you have any skin conditions?*

YesNo
If yes, which skin conditions?
Do you have any blood-borne diseases? (e.g. Hepatitis C, HIV)*

YesNo
Do you have any illnesses or are you feeling sick? (e.g. cold, diabetes)*

YesNo
Have you eaten anything in the last 4 hours?*

YesNo
Are you going abroad in the next 4 months?*

YesNo
Name*

First nameLast name
Email*
example@example.com
Where do you live?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Would you like to receive our newsletter?

YesNo
Are you younger than 18?*

YesNo
Date of birth*

DayMonthYear
Date
Phone number*

I confirm that I have approved both the jewelry and the placement of my piercing. I understand that jewelry used for piercings is non-returnable.
What kind of jewelry*

HoopLabret
I confirm that I have been informed about the challenges of getting pierced with a hoop. Due to the shorter post, the piercing requires extra care and attention during the healing process.
At ENNUI Atelier follow-up visits are included. I understand that if any concerns or issues occur, I should contact ENNUI Atelier for the best possible assistance.
Should be Empty: