Permanent Jewelry Consultation Form
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Email
example@example.com
Number
Please enter a valid phone number.
Would you like to be added to our email list for special discounts?
Yes
No
How did you hear about us?
Have you ever had an adverse or allergic reaction to jewelry or metal?
Yes
No
If yes, please describe
List any medication and medical conditions that could impact your ability to receive the jewelry:
By Clicking Submit You Acknowledge The Following:
I completed the above form to the best of my knowledge. I have had the opportunity to ask any questions and have received satisfactory answers. I will inform the technician of any changes to the above information. I am over the age of 18 and consent to the procedure. If I am under the age of 18, a parent or guardian must sign. I will not hold the technician/jeweler, salon, or employees liable for any issues not disclosed at the time of my service or any adverse effects from the procedure.
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Permanent Jewelry Consent Form
Permanent jewelry is a process that involves the use of welding the jewelry together while on your body. the procedure is generally painless and is performed with your safety in mind. This consent form is intended to inform you of the risks of the procedure and to obtain your informed consent for the procedure.
I understand that although rare, an allergic reaction to the jewelry can occur.
I consent
I understand that the welding procedure does have some risks; including but not limited to potential allergic reactions, irritation, discomfort, burns, and scarring.
I consent
I agree to the jewelry care instructions recommended by the technician.
I consent
I understand that although this jewelry is intended to be permanent, durable and long-lasting, the length of wear can vary depending on my physical activity and other factors.
I consent
I understand that there may be some instances where I will be required to remove my jewelry, including but not limited to medical procedures like MRI and surgery. I understand that the jewelry can easily be removed with scissors and re-attached by the jeweler at a later date.
I consent
I give the technician/jeweler permission to photograph my jewelry and procedure for their own marketing and promotional purposes.
I consent
By Clicking Submit You Acknowledge The Following:
I completed the above form to the best of my knowledge. I have had the opportunity to ask any questions and have received satisfactory answers. I understand the risks and potential side effects associated with the permanent jewelry procedure. I understand that the results of the procedure are not guaranteed and may vary from person to person. I am over the age of 18 and consent to the procedure. If I am under the age of 18, a parent or guardian must sign. I will not hold the technician/jeweler, salon, or employees liable for any issues not disclosed at the time of my service or any adverse effects from the permanent jewelry procedure. This agreement remains in effect for this procedure and any follow-up appointments.
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