Body Piercing Consent Form

Revive Medical Tattooing & Body Piercing

4021 Calloway Dr. STE 600/700 Bakersfield, CA 93312
Body Piercing Consent Form

Before and After Care Instructions: https://drive.google.com/file/d/10v8vv-ea9cUEdUMtV-lrQs03l9E6Bykz/view?usp=sharing
This agreement is between the client and the body piercer at Revive Medical Tattooing & Body Piercing. This agreement confirms that complete communication has occurred to ensure a legal, safe, and successful body piercing.
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Client Age*
Are you signing on behalf of a minor under 18 as their parent or guardian? If you are 18 or older, please enter N/A.*
LEGAL GUARDIANS NAME or N/A if 18 or older.*
ID Number*
Photo of ID*

Cancelof
Minor's Birth Certificate

Cancelof
I am 18 years of age or older OR I have parental consent for this piercing.*
Have you eaten within the last 2 hours prior to your appointment?*
Do you have any allergies that we should be aware of? Such as latex, iodine, stainless steel, titanium or any other products that we may use?*
Have you taken any blood thinners, such as ibuprofen or aspirin, within the 24 hours leading up to your body piercing procedure?*
Have you consumed alcohol or any intoxicants in the 24 hours leading up to your body piercing procedure?*
YES/NO
Are you prone to fainting?*
Are you pregnant or nursing?*
I have provided my own jewelry and take full responsibility for it.*
I understand that the piercer cannot be held responsible if my body reacts negatively to the metal of the jewelry use.*
I understand that I am fully responsible for the care of my piercing.*
I understand that receiving a body piercing carries risks, including fainting, vomiting, and infections that can include bacterial endocarditis for individuals with heart conditions.*
Please list any of the following conditions you have: heart disease, diabetes, epilepsy, HIV/AIDS, hepatitis, keloids, heavy bleeding pregnancy, or cold sores.*
I consent to Revive Medical Tattooing and Body Piercing using photos/videos of my piercing for promotional and educational purposes. I understand my identity may be visible unless requested otherwise and waive any rights to compensation. I may revoke this consent in writing before use.
I confirm that I have answered all the above questions truthfully. *
I fully understand and accept responsibility for the piercing process, associated risks. healing time, and daily after care procedures. *
I acknowledge that I have been informed that body piercing involves permanent changes to the skin. I further acknowledge that infection, scarring, allergic reactions, and other complications may occur as a result of receiving body art services. I accept full responsibility for any such outcomes and consent to proceed with the procedure*

I understand and accept
I understand that if I show any of the following signs of infection, I should contact a health care provider immediately. Signs and symptoms of infection, including, but not limited to, redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent drainage from the procedure site.*
I hearby release Revive Medical Tattooing & Body Piercing and my piercer from any and all liabiity related to my body piercing procedure.*
Date*

MonthDayYear
Date
All information gathered from the client that is personal medical information and that is subject to the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or similar state laws shall be maintained or disposed of incompliance with those provisions.
FOR PIERCER USE ONLY- Do not fill out for your piercer.
Body Piercers Name*

First NameLast Name
Body Piercers Signature*
Date*

MonthDayYear
Date
Piercing Type*
After care instructions given.*
Aftercare products recommended.*
Return appointment advised.*
PLEASE DO NOT SUBMIT THIS FORM; YOUR BODY PIERCER WILL SUBMIT ONCE YOU ARE CALLED FOR YOUR APPOINTMENT.
Should be Empty:

Revive Medical Tattooing & Body Piercing

Body Piercing Consent Form

YES/NO

FOR PIERCER USE ONLY- Do not fill out for your piercer.

PLEASE DO NOT SUBMIT THIS FORM; YOUR BODY PIERCER WILL SUBMIT ONCE YOU ARE CALLED FOR YOUR APPOINTMENT.