Piercing Request Form
please fill out all necessary information below
Name
First Name
Last Name
Age (no minors will be pierced regardless of parental consent)
Email
example@example.com
Phone Number
Please enter a valid phone number.
Select Piercing
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next
( X )
Nipple
$
45.00
Quantity
1
2
Tragus
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Eyebrow
$
45.00
Quantity
0
1
2
Earlobe
Please enter a short description.
$
35.00
Quantity
0
1
2
3
4
5
Conch
$
50.00
Quantity
0
1
2
3
4
5
Rook
$
60.00
Quantity
1
2
3
4
5
6
7
8
9
10
Flat
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
Conch
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Industrial
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Snug
$
60.00
Quantity
1
2
3
4
5
6
7
8
9
10
Daith
$
70.00
Quantity
1
2
3
4
5
6
7
8
9
10
Vertical Labret
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Medusa
$
60.00
Quantity
1
2
3
4
5
6
7
8
9
10
Monroe
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Ashley
$
70.00
Quantity
1
2
3
4
5
6
7
8
9
10
Tongue
$
50.00
Quantity
1
2
3
4
5
6
7
8
9
10
Smiley
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
Tongue web
$
60.00
Nostril
$
45.00
Quantity
1
2
3
4
5
6
7
8
9
10
Septum
$
60.00
Quantity
1
2
3
4
5
6
7
8
9
10
Navel
$
45.00
Eyebrow
$
45.00
Quantity
1
2
3
4
5
6
7
8
9
10
Bridge
$
75.00
jewelry
$
10.00
Quantity
1
2
3
4
5
6
7
8
9
10
jewelry removal
$
10.00
Quantity
1
2
3
4
5
6
7
8
9
10
jewelry change
$
10.00
Quantity
1
2
3
4
5
6
7
8
9
10
Notes & questions you want to add
Appointment
I agree with the following statements:
I will provide photo ID.
I will read and sign piercing consent form and acknowledge aftercare instructions.
I will be responsible and respectful to others in the building by maintaining a low volume during my appointment.
I understand there is a nonrefundable deposit required to book an appointment.
I understand failure to arrive on time, failure to bring a valid ID or failure to reschedule within 24 hours will result in forfeiture of deposit.
Signature
Submit
Submit
Should be Empty: