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?
Are you pregnant or breastfeeding?
Do you faint easily?
Are you allergic to rubber or latex?
Do you have any skin conditions?
If yes, which skin conditions?
Do you have any blood-borne diseases? (e.g. Hepatitis C, HIV)
Do you have any illnesses or are you feeling sick? (e.g. cold, diabetes)
Have you eaten anything in the last 4 hours?
Are you going abroad in the next 4 months?
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?
Are you younger than 18?
Date of birth

DayMonthYear
Date
Phone number
Format: +(00)00 000 00 00.
- Guardian's name
  
  First nameLast name
- Guardian's email
  example@example.com
- Guardian's date of birth
  
  YearMonthDay
  Date
- Guardian's signature
- What kind of jewelry
- Should be Empty: