Piercing Consent Waiver

Piercing Consent Waiver
Client Information
Legal Name

First NameLast Name
Name you Go By

First NamePronouns
Birth Date

MonthDayYear
Date
Email
example@example.com
Pre-Procedure Questionnaire
Piercing Type(s)
Please specify the type of piercing you are receiving today (i.e. earlobe, nostril, etc)
Are you experiencing flu symptoms at the time of your appointment?
Are you pregnant or suspect you may be pregnant?
Are you under the influence of any drugs or alcohol?
Do you have any skin conditions affecting the piercing site? (i.e. eczema, psoriasis, rash, etc.)
If yes, please identify the condition.
Do you have any relevant allergies or sensitivities? (i.e. latex, iodine, metals, etc.)
If yes, please specify the allergy and severity.
Do any of the following conditions apply?
I understand, that like any invasive procedure, body piercing may involve possible health risks. These risks may include: Pain, bleeding, swelling, infection, scarring of the area, and nerve damage. Unsterile equipment and needles can spread infections diseases; it is extremely important to be sure that all equipment is clean and sanitary before use. I may not be able to donate blood either temporarily or permanently, depending on the guidelines of the blood donation service I use.
I consent to Rubi's Piercing capturing photos of my piercing. I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form.
Client Signature
Signed Date

MonthDayYear
Date
Photo ID:

Cancelof
Should be Empty:

Piercing Consent Waiver

Client Information

Pre-Procedure Questionnaire