APPOINTMENT REQUEST FORM
Piercing
Personal information
Please fill in the boxes below.
Name (as shown on photographic ID)
*
First Name
Last Name
Preferred name
Any chosen for yourself or nickname.
Preferred pronouns
e.g. she/her, he/him, they/them
Date of birth
*
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Month
-
Day
Year
Email address
*
example@example.com
Contact number
*
Please enter a valid phone number.
Instagram handle
e.g. @pyxiepiercings
I am happy to be contacted via Instagram and will check my message requests if necessary. (If yes, please make sure you’re following me @pyxiepiercings as some profile settings restrict me from contacting you if you’re not!)
Yes
No
The whats, wheres and whens
Tell me more!
Which service(s) would you like to book?
*
Piercing
Jewellery upgrade
Downsize
Please provide any further information on the service(s) you’d like.
*
Please note that I am only able to do up to three piercings per person per day, depending on what and where, with the exception of four ear lobe piercings. If you would like more than the limit, please enter all and we can discuss multiple appointments.
If you have a vision for your piercing, including placement or jewellery choice, please upload any relevant images.
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When are you available? (Select all that apply.)
*
Mondays ☆ Rye Lanez, Peckham
Tuesdays ☆ Rye Lanez, Peckham
Thursdays ☆ Briar Rose, Hither Green
Fridays ☆ Briar Rose, Hither Green
Saturdays ☆ Briar Rose, Hither Green
Late night Thursdays (until 8:30pm, first Thursday every month) ☆ Briar Rose, Hither Green
When would you like to get pierced?
*
As soon as possible
I have a specific date in mind
If you have a date in mind, please pick below.
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Month
-
Day
Year
Please note that I don’t work Wednesdays or Sundays!
Extra information
Remember: it’s all confidential.
Are you taking any medication? If yes, please specify.
*
All are relevant.
Do you have any medical conditions?
*
Some can pose health risks or affect healing, so I will need to know prior to your appointment.
Do you have any extra requirements to make your experience more suited to you?
*
This can include a quiet room, assistance of a carer, a longer appointment for learning/behavioural difficulties, sensory aid and more. Say the word!
I acknowledge that I will be required to pay a non-refundable deposit to secure any appointment made; the amount is subject to factors such as service charge and jewellery fee, and will be determined by Bell. Any amount paid upfront will be deducted from the total cost.
*
I agree
Cancellations or rescheduling must be made at least 24 hours before your appointment, or you risk losing your deposit. Some emergencies may apply and I will contact Bell as soon as I know of any changes that need to be made.
*
I agree
I understand that this form does not automatically guarantee an appointment, and that I will be contacted by Bell within 2-3 days of submission. I confirm that the person wanting the piercing(s) is 16 years old or over, and can provide photographic ID (passport or drivers/provisional license) on the day of my appointment.
*
I agree
Submit
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