Piercing Consent Form

Body Piercing Consent Form
Client Information
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please select the conditions you have:*

AnxietyEczamaEpilepsyHaemophiliaHeart ConditionHIVInk AllergyLatex AllergyNickel AllergyPregnancyTuberculosisNONE OF THIS ARE APPLICABLE TO MEOther
HOW DID YOU HEAR ABOUT US?*

REFERRED BY FRIEND (put name in "other comments" at bottom of page.99.7 THE BLITZ RADIO ADDRIVE BY, SAW SIGNSGOOGLE ADSSHOP INSTAGRAM (@stoicbodyart)SPECIFIC ARTIST INSTAGRAM (Put name in "other comments" at bottom of page)SHOP TIK TOK (StoicBodyArt)SHOP FACEBOOK (STOIC BODY ART)Other
I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a body piercing or microdermal (single point piercing) and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows:*

I Agree
I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart conditions or take medication which thins the blood. I have informed my Piercer of any condition such as diabetes that might hamper the healing of the piercing.*

I Agree
If I suffer from hepatitis, or any other communicable disease, I have informed the Piercer of this fact and I have been advised of any procedures necessary to promote the satisfactory healing of my piercing.*

I Agree
I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds, infections, rashes, or lesions at the site of the piercing.*

I Agree
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 a reaction is possible.*

I Agree
I have trustfully represented to the Piercer that I am over the age of eighteen (18) years. 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.*

I Agree
I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to restore the skin involved in this piercing to is pre-piercing condition.*

I Agree
I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and agree to follow all of them while my piercing is healing.*

I Agree
I understand that a microdermal (single point piercing) consists of a pierced point of entry but not a point of exit. Specially designed jewelry is inserted into the pierced area and sits below the skin where it becomes anchored.*

I Agree
I understand I will be pierced using appropriate instruments and sterilization.*

I Agree
I understand that "Stoic Body Art" / "Mattattooo LLC" reserves all rights to use any photos of my piercing or tattoo taken in "Stoic Body Art" / "Mattattooo LLC" by any of the piercers, artists, counter staff, shop help, etc... and release them of any liability regarding the posting, sharing or use of the photos on the shop website. (If this is a genitalia piercing, please check the appropriate box)*

I acknowledge this & Agree (regular piercing)I acknowledge this & DO NOT agree (genitalia piercing)I acknowledge this & AM OKAY with sharing photos (genitalia piercings)
Therefore, I request the Piercer at "Stoic Body Art"/"Mattattooo LLC" to piercer my NAME OF PIERCING* . I understand that most piercings take anywhere from four to twelve weeks to heal, sometimes longer. I hereby release and forever discharge and hold harmless "Stoic Body Art" / "Mattattooo LLC", the piercer and all affiliates, owners, managers and employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing, to the fullest extent allowed by the law.
By signing below, I First Name* Last Name* , or their legal guardian, agree that I have read the Body Piercing Release form provided by "Stoic Body Art" / "Mattattooo LLC", and agree to its terms.
PLEASE SIGN HERE TO COMPLETE YOUR CONSENT FORM FOR YOUR BODY PIERCING PROCEDURE. THANK YOU FOR YOUR TIME!*

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Signed Date*

MonthDayYear
Date
UPLOAD YOUR DRIVER LICENSE, PASSPORT OR STATE IDENTIFICATION (For minors, please upload; your birth certificate, your photo identification & your parent's drivers license or Identification. The last names must match on the ID's, or the birth certificate must have the same names. If you have a legal guardian, please upload documentation of that as well.*

Cancelof
PLEASE SIGN HERE IF YOU ARE THE PARENT OR GUARDIAN OF THE MINOR GETTING THE PIERCING PROCEDURE DONE. * If this does not apply, then leave blank.*

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PLEASE PROVIDE ANY OTHER COMMENTS HERE IF YOU NEED TO. THIS INCLUDES ANY SPECIFICS REGARDING HOW YOU WERE REFERRED TO US AS WELL AS ANYTHING YOU WOULD LIKE TO SUGGEST FOR US TO CHANGE TO MAKE EASIER FOR YOU, THE CLIENT! THANK YOU!*
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Body Piercing Consent Form

Client Information