Desert Diamondz Piercing Consultation
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Today's Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
What piercing(s) are you inquiring about? Example: (ear, nose, belly button etc)
Health and Medical Information
Rows
Yes
No
Have you been diagnosed with Hepatitis , HIV or any communicable disease?
Do you have Diabetes?
Are you taking any blood thinner?
Do you have difficulty in stopping of bleeding?
Do you have heart-related concerns?
Are you pregnant? (for females)
Do you have any allergies?
Please explain
Rows
Yes
No
Did you consume any alcoholic drink or taken drugs in the past 8 hours?
Have you consumed food in the past 2 hours?
Do you have any condition that might affect your bodily healing?
If yes, please explain
I hereby declare that the information I have specified above is true and correct to the best of my knowledge which may otherwise give adverse effects, should I undergo any of the services. I have been informed by my piercer/artist that any conditions that would exist before the procedure would hamper the healing process of my body. I have been advised by my piercer/artist regarding any allergies, including allergic reactions to latex, metals, and/or medications.
I understand that the procedure shall be done with proper techniques and properly sanitized instruments. In no case, I acknowledge infection is always possible after a procedure. I have received aftercare instructions and agree to follow all of them while my piercing is healing.
By signing this form, I hereby release, forever discharge and hold harmless the company, its employees, owners, managers, directors, partners, and affiliates from any and all claims for liabilities and damages or hold them liable for any criminal or civil proceedings arising from or connected to the procedure undertaken.
I am executing this indemnity form with full knowledge and understanding to its legally binding effect and all sales are final. I acknowledge that I am of legal age giving my full consent to this indemnity agreement, without representation, inducement, or coercion.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: