Piercing Consent 2024

Body Piercing Release
Please read through the form below and fill out necessary personal information, provide a copy of your ID and provide your signature at the bottom. You must be 18 years of age with State or Federal issued identifiction to be pierced or you must be at least 16 years of age with a parent or legal gaurdian present and both must have identification.
Customer Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
UPLOAD PHOTO ID(S)*

Cancelof

Minor information *

	Yes	No
Are you under 18? If so you have a parent/guardian present with proper identification?

Date of Birth

MonthDayYear

Health and Medical Information*

	Yes	No
Have you been diagnosed with Hepatitis 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?
Did you consume any alcohol or drugs in the past 8 hours?
Have you consumed food in the last 2 hours?
Have you ever fainted before

Do you have any allergies?*
Please explain
Do you have any condition that might affect your bodily healing?*
If yes, please explain
Piercing Location
Piercing Location*

LobesHelixConchTragusRookDaithIndustrialForward HelixTongueLabretMedusaMonroeEyebrowBridgeNostrilSeptumNavelNipplesVCH
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 that any conditions that would exist before the procedure would hamper the healing process of my body. I have been advised by my Piercer regarding any allergies, including allergic reactions to latex, metals, and/or medications.

I understand that changes made to my body shall be permanent and without possibility of reversal. I like wise understand that the Piercer performing the procedure is not a healthcare professional. I understand that the procedure shall be done with proper techniques and properly sanitized instruments. 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. I acknowledge that I am of legal age giving my full consent to this indemnity agreement, without representation, inducement, or coercion.
Signature*

Clear
Date*

MonthDayYear
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Body Piercing Release

Customer Information