Piercing Consultation Form
Please fill out the form to schedule your piercing appointment.
Contact Information
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone Call
Text Message
Other
Date of Birth
-
Month
-
Day
Year
Date
Piercing Experience
Which type of piercing are you interested in?
Lobe $45
Lobe Set $85
Cartilage/Helix $60
Forward Helix $80
Tragus $80
Rook $80
Anti-Tragus/Snug/Conch $80
Daith $80
Industrial $100
Lip/Labret/Monroe $80
Vertical Lip $80
Horizontal Lip $80
Medusa $80
Snake bites $150
Tongue $120
Venom $220
Cheek (dimple) $100
Navel $80
Nipple $100
Nipple Set $140
Surface $100
Nose $80
Bridge $80
Septum $100
Eyebrow $80
Anti-Eyebrow $90
Have you had any previous piercings?
Yes
No
If yes, please describe your experience:
Medical Disclosure
Please discuss any medications, allergies, or medical history with your tattoo professional prior to your procedure.
Do you have any allergies or medical conditions we should be aware of?
Please select any health conditions that apply, then discuss with your artist.
Diabetes
Bleeding Disorder
Skin Condition
Latex or Pigment Allergy
Heart Condition
Epilepsy
Communicable Disease
Pregnant/Nursing
Low/High Blood Pressure
Other
Are you on any medications that may thin your blood or inhibit your ability to receive or heal your piercing?
Yes
No
If yes, please note.
Do you confirm you will have eaten within the last two hours of arriving at your appointment?
Yes
No
Do you confirm you will not be under the influence of drugs or alcohol (more than 2 drinks) at the time of your appointment?
Yes
No
Please read and agree to each of the following before moving forward. If you have trouble understanding, or questions about anything please let your artist/piercer know so that they can assist you.
*
I certify that I am 18 years of age, or a minor with proper parental consent and documentation.
I understand that there is a possibility of allergic reaction, infection, or health complications.
I agree to follow all instructions regarding the aftercare process of my piercing.
I understand there is a chance I might feel lightheaded, dizzy and/or faint due to my decision to receive a tattoo or piercing and will notify my artist if this happens. Failure to do so releases all artists of any and all responsibility.
I understand it is my responsibility to check placement and approve all aspects to ensure the placement meets my specifications.
I understand there are no refunds once work has been completed.
I understand that the artist has the right to discontinue service if I become disrespectful, rude, or too difficult to pierce at my own expense.
I hereby release all service providers of all responsibility for services I receive within.
I understand a $25 deposit will be required to secure my appointment. Deposit is payable by E-Transfer.
Appointment
Please specify your ideal date and time for your appointment. This is NOT a guaranteed time. We do our best to accommodate requests and will be in contact as soon as possible to confirm availability!
Additional Questions or Concerns
Submit
Should be Empty: