Piercing Consent Form

Piercing Consent Form

Please complete this form to provide your legal consent for a piercing procedure at Sacred Art, in compliance with Florida state health department regulations. (Sacred Art Management LLC)
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Upload a Picture of Your Driver's License*

Cancelof
Piercing Details
Please describe what you are getting pierced*
Be specific (Right ear, Left nostril, etc.)
Emergency Contact Information
Emergency Contact Full Name*

First NameLast Name
Relationship to Emergency Contact*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please list any allergies (including metals or latex) or medical conditions (such as bleeding disorders, diabetes, skin conditions, etc.) that may affect the piercing procedure.*
Are you currently taking any medications, including blood thinners or antibiotics? If yes, please specify.*
Have you eaten in the last 4 hours?*

YesNo
Client Signature (Please sign below to authorize the piercing procedure)*
Should be Empty:

Piercing Details