Piercing Consent Form

Piercing Consent Form
Please read this form carefully and provide accurate information. This consent form is required by Ontario health regulations to ensure your safety and well-being during the piercing procedure.
Name

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

MonthDayYear
Date
Client Identification *

Driver's License / Health Card / Passport / Proof of Age Card
Cancelof
**If you are under 18, or filling this form out on behalf of someone under 18, there is a section for a Parent / Guardian to complete below. If the client does not have any form of ID, you may upload a blank picture under "Client Identification".
Emergency Contact Name*
First & Last Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Type of Piercing:*
Ear (Lobe, Conch, Daith, Industrial, Rook, Tragus) / Nose / Septum / Navel / Eyebrow / Nipple
Location of piercing:*
Left / Right / Both
Date Of Your Appointment*

MonthDayYear
Date
Age
Please acknowledge the following items:*

I confirm that I will not be under the influence of drugs or alcohol during this procedure.I understand that there are risks involved with body piercing including, but not limited to: infection, allergic reaction, scarring, nerve damage, migration, and rejection.I understand that healing times vary and it is my responsibility to follow the aftercare instructions provided to ensure proper healing.I understand that The Lady G Tattoos uses sterile, single-use equipment and follows all public health guidelines.I understand I will be given the opportunity to ask any questions about the piercing procedure, risks, and aftercare, and will not proceed unless all of my questions have been answered to my satisfaction.I am not currently pregnant or breastfeeding.I am not currently taking blood thinners or any medications that may affect healing.I do not have any communicable diseases including but not limited to blood-borne illnesses (e.g. Hepatitis, HIV), heart conditions, diabetes, epilepsy or seizures, allergies to metals, latex, antiseptics, or numbing agents, or skin conditions (e.g. eczema, psoriasis).I release the shop, its administrators, practitioners, stakeholders and workers from any and all of the claims, expenses, liabilities and damages.
I consent to photographs of my piercing being taken for the artist's portfolio/ website:*

YESNO
I consent to being tagged on social media when my piercer posts a picture of my piercing:*

YESNO
My social media handle is:
Medical History

Leave blank if not applicable
Allergies

LatexMetalsOther
Other:
Please provide details
Medications
Example: Blood Thinners
Conditions
Example: Type 1 Diabetes
Other
Any other relevant information pertaining to your medical history or that you would like us to know.
I acknowledge that I have truthfully represented myself to the Muskoka Tattoo Collective and its employees and that I am at least 18 years of age and am competent to sign this agreement. If I am not 18 years of age, my legal guardian is in complete agreement with the conditions set out above and shall sign on my behalf.*

I agree to this statement
Client Signature*

Clear
Today's Date*

MonthDayYear
Date
Signature of Legal Guardian (if applicable)*

Clear
Today's Date*

MonthDayYear
Date
Name of Legal Guardian*
Full Name
Relationship of Guardian to Client*
Parent / Guardian / Grand Parent etc
Guardian's Date of Birth*

MonthDayYear
Date
Guardian Contact Information*
Phone and/or email address
Picture of Guardian's Identification / Proof of Age*

Cancelof
Is there anything else you'd like us to know?
STUDIO USE ONLY
TOOL INFORMATION
Expiries & Lot Numbers
JEWELRY INFORMATION
Piercer Signature*

Clear
Date*

MonthDayYear
Date
YES
Artist Signed?
Should be Empty:

Piercing Consent Form

Medical History

STUDIO USE ONLY