Welcome to Paradise
Piercing consent form
Personal informations
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Please talk to a piercer if you are under 16*
Phone number
Email
example@example.com
Pre-Procedure Questionnaire
Please select the appropriate answer
Desired piercing
*
Ear cartilage
Ear lobes
Nostril
Septum
Lip (...)
Nipple
Navel
Dermal/surface
Eyebrow
Bridge
Other
Are you pregnant or nursing?
*
Yes
No
Are you under the influence of drugs and/or alcohol? (Prescription narcotics included)
*
Yes
No
Do you suffer from heart conditions and/or blood-thinning disorders such as hemophilia?
*
Yes
No
Do you have epilepsy, diabetes or anemia?
*
Yes
No
If you selected yes, please specify:
Do you have allergies to metals, medications, etc?
*
Yes
No
If you selected yes, please specify:
Do you have a phobia of needles and/or blood?
*
Yes
No
Did you take blood thinning medications (ex : aspirin) in the last 24 hours?
*
Yes
No
Did you ever have a negative piercing experience in the past?
*
Yes
No
Do you have a tendency to faint?
*
Yes
No
If you selected YES to any of the previous questions, you commit to informing your piercer as such.
*
I commit
Release of all claims
Please read thoroughly :
Date
-
Month
-
Day
Year
Date
Client Signature
Submit
Should be Empty: