BODY PIERCING CONSENT FORM

BODY PIERCING CONSENT FORM

This is an agreement between the piercer and the client, indicating that full communication has taken place to ensure a legal, safe and successful body piercing
Name*

First NameLast Name
Adresse/Suburb/post code *
Phone Number*

Area CodePhone Number
Email*
example@example.com
Age*
I.D sighted *
IF SIGNING FOR AN UNDER 18 YEARS OLD ARE YOU ?

ParentsLegal guardian
Your NAME*
LICENCE NUMBER *
Confidential information (discuss each questions with the piercer) please answer by yes or no
I am 18 years of age or older or have parental consent for this piercing*

YesNo
Have you eaten within the past 4 hours ?*

YesNo
Have you been drinking alcohol within the last 8 hours*

YesNo
Are you currently taking any non prescribed drugs ?*

YesNo
Are you currently taking any medication ?*

YesNo
Are you prone to fainting ?*

YesNo
Do you have any fears around medical types procedures ?*

YesNo
I understand that the piercer can't be held responsible if my body react negatively to the metal of jewellery *

YesNo
I understand that the piercer suggestions are not tone confused with medical advice*

YesNo
I understand that I am totally responsible for looking after my piercing *

YesNo
I understand that sterilised jewellery and equipment and / or single use disposables will be used for my piercing*

YesNo
Please indicate (by check the box) if any of the following conditions apply to you*

Heart DiseaseDiabetesEpilepsyH.I.V/ A.I.D.SHepatitsKeloidingHeavy BleedingPregnancyCold Sores
STATEMENT OF CONSENT
This is to certify that I, the above named and undersigned, do give my permission to be pierced at Business Name Spiral piercing & concept store.

I have answered all of the above questions truthfully.

I am fully aware of and take full responsability for the piercing process, the healing and the daily aftercare procedure
Customer signature*

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Date

JourMoisAnnée
Date
Body Piercer's signature

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Date

JourMoisAnnée
Date
*The piercer's signature is assurance of correct procedure, sterillization, and client education
Jewellery gauge used
Jewellery size used
Jewellery metal used
Jewellery style used
NOTE BY PIERCER

On arrival & Pre Procedure instruction annd advice given about procedure to client.

Special Circumstance /Considerations All special needs are taken into consideration

During procedure Procedure and a step by step given to client during whole procedure

Post Piercing After care instructions and how to prevent infection given to client during whole procedure

Aftercare instruction given YES Aftercare product given optional
Should be Empty: