Appointment Request Form

1
Full Name
First Name
Last Name
2
Contact Number
Please enter a valid phone number.
3
Email Address
example@example.com
4
Piercing or Tattoo appointment?
Please Select
Please Select
Piercing
Tattoo
Both
5
What date and time work best for you?
6
Please provide inspo Pictures and placementPlease make sure images are visible
7
Any other specific date and time, if the above selection is not suitable.
Date
Month
Day
Year
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Hour
36
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Minutes
PM
AM
PM
8
SignatureI acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a piercing/tattoo and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows:•If I have any condition that might affect the healing of this piercing/tattoo, I will advise my Artist. I am not pregnant or nursing. I am not under the influence of alcohol or drugs•I do not have medical or skin conditions such as but not limited to: acne, scarring (Keloid) eczema, psoriasis, freckles, moles or sunburn in the area to be pierced/tattooed that may interfere with said piercing/tattoo. If I have any type of infection or rash anvwhere on my body, I will advise my Artist. I acknowledge it is not reasonably possible for the representatives and employees of this shop to determine whether might have an allergic reaction to the pigments or processes used in my piercing/tattoo, and I agree to accept the risk that such a reaction is possible. I acknowledge that infection is always possible as a result of the obtaining of a piercing/tattoo, particularly in the event that I do not take proper care of my piercing/tattoo. I have received aftercare instructions and I agree to follow them while my piercing/tattoo is healing. I agree that any touch-up work or jewelry down sizing needed, due to my own negligence, will be done at my own expense. I realize that variations in color and design may exist between any tattoo/piercing as selected by me and as ultimately applied to my body. I understand that if my skin color is dark, the colors will not appear as bright as they do on light skin. I understand that if I have any skin treatments, laser hair removal, plastic surgery or other skin altering procedures, it may result in adverse changes to my piercing/tattoo. I acknowledge that a piercing/tattoo is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove my piercing/tattoo. To my knowledge, I do not have a physical, mental or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a piercing/tattoo. I acknowledge I am over the age of eighteen and that I have truthfully represented to my artist that the obtaining of a piercing/tattoo is by my choice alone. I consent to the application of the piercing/tattoo and to any actions or conduct of the representatives and employees of the shop reasonably necessary to perform the piercing/tattoo procedure.
Should be Empty: