PIERCING CONSENT FORM

PIERCING CONSENT FORM

18+
Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact *

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Drivers License # (18 and older)*
Drivers License Photo Front
Are you currently taking any blood tinners or medications that may affect healing?*

YesNo
IF YES, Please List Medications
PIERCING REQUESTED
FLAT (LEFT)HELIX (LEFT)MID HELIX (LEFT)FORWARD HELIX (LEFT)LOBE 1 (LEFT)LOBE 2 (LEFT)LOBE 3 (LEFT)STACK (LEFT)TRAGUS (LEFT)CONCH (LEFT)
FLAT (RIGHT)HELIX (RIGHT)MID HELIX (RIGHT)FORWARD HELIX (RIGHT)LOBE 1 (RIGHT)LOBE 2 (RIGHT)LOBE 3 (RIGHT)STACK (RIGHT)TRAGUS (RIGHT)CONCH (RIGHT)
Initial* I am NOT pregnant or nursing. If I have any condition that might effect the healing process of the selected piercing, I will inform the Piercer
Initial* I do NOT suffer from medical conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of piercing or any open wound or lesions at the site of piercing, Diabetes, or a Heart Condition
Initial* I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such reaction is possible.
Initial* I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time.
Initial* I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change of appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition.
Initial* I acknowledge that infection is always possible as a result of obtaining a piercing. I have received aftercare instructions from the Piercer and I agree to follow all of them while my piercing is healing,
Initial* I understand I will be pierced using appropriate instruments and sterilization
I have read and understand the above information. By signing below, I acknowledge that I consent to the piercing procedure selected above and release Halo Grace Piercing Co. & Piercer from any and all liability from this procedure
Date*

MonthDayYear
Date
Signature*

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PIERCING CONSENT FORM

PIERCING REQUESTED