Piercing Consent Waiver
Client Information
Legal Name
*
First Name
Last Name
Name you Go By
First Name
Pronouns
Birth Date
*
-
Month
-
Day
Year
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?
*
Yes
No
Are you pregnant or suspect you may be pregnant?
*
Yes
No
Are you under the influence of any drugs or alcohol?
*
Yes
No
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?
*
Please Select
None
Diabetes
Hemophilia
Any condition requiring blood-thinning medication
Anemia
Epilepsy
History of fainting or Vasovagal Syncope
Hepatitis or HIV
Medically diagnosed keloid formation
*
I will follow aftercare instructions given to me by Rubi's Piercing to the best of my ability. I understand that straying from the recommended aftercare instructions may cause complications during the healing process of my piercing.
*
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 understand that the body art practitioner should: Properly cleanse the area before piercing; use sterilized equipment; use sterile techniques; and provide information on the aftercare.
*
I consent to my piercing procedure and acknowledge that it will result in a permanent change to my appearance. I understand that my skin may not be restored to its pre-piercing condition even after its removal.
*
If there is any injury, infection, or complication, I will notify this establishment and the Watertown Public Health Department at (617) 972- 6446.
*
I understand that all information disclosed will be kept confidential and a copy will be provided to me upon request.
*
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
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.
*
Yes
No
Client Signature
*
Signed Date
*
-
Month
-
Day
Year
Date
Photo ID:
*
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*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record.
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