Permanent Jewelry Consultation + Consent Form

Permanent Jewelry Consultation Form
Name
Birthdate

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Zip
Cell phone
Email address
example@example.com
Have you ever had an adverse or allergic reaction to jewelry or metal?
If yes, please describe
Permanent Jewelry Consent Form
PERMANENT JEWELRY IS A PROCESS THAT INVOLVES THE USE OF WELDING THE JEWELRY TOGETHER WHILE ON YOUR BODY. THE PROCEDURE IS GENERALLY PAINLESS AND IS PERFORMED WITH YOUR SAFETY IN MIND. THIS CONSENT FORM IS INTENDED TO INFORM YOU OF THE RISKS OF THE PROCEDURE AND TO OBTAIN YOUR INFORMED CONSENT FOR THE PROCEDURE.

I understand that although rare, an allergic reaction to the jewelry can occur.

I understand that the welding procedure does have some risks; including but not limited to potential allergic reactions, irritation, discomfort, burns, and scarring.

I agree to the jewelry care instructions recommended by the technician.
I understand that although this jewelry is intended to be permanent, durable and long lasting, the length of wear can vary depending on my physical activity and other factors. Initial below.*
I understand that there may be some instances where I will be required to remove my jewelry, including but not limited to medical procedures like MRI and surgery. I understand that the jewelry can easily be removed with scissors and re attached by the jeweler at a later date. Initial below.*
I give the technician/jeweler permission to photograph my jewelry and procedure for their own marketing and promotional purposes. Initial here if agreed.
Client or Guardian Signature

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Date

MonthDayYear
Date
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Permanent Jewelry Consultation Form

Permanent Jewelry Consent Form