Piercing Consent Form
Legal Agreement for Piercing Procedures
Client Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any of the following medical conditions? (Select all that apply)
*
Suffers from any heart conditions(e.g. prosthetic heart valve/ heartvalve disease/ angina/ bloodpressure problems)?
Suffers from epilepsy?If Yes, how controlled?
Suffers from haemophilia/otherclotting disorders?
Suffers from diabetes or lupus?
Suffers from any problems withskin healing in the past, e.g.psoriasis, eczema?
Suffers from any known allergicresponses eg plasters/creams/metals/iodine/shellfish/latex/foodstuffs/other? Indicate which:
Takes any prescribed medicationregularly (especially anyanticoagulants such as Warfarinor high dose asprin; any immunosuppressants such as steroids)?
Is the client pregnant?
Prone to ‘fainting attacks’?If yes, state reason:
Any previouspiercings at proposed site?
Are you currently taking any medications? If yes, please list them below.
Have you consumed alcohol or recreational drugs in the past 24 hours?
*
Yes
No
Location of Piercing (e.g., ear, nose, navel, etc.)
*
I confirm that I am at least 18 years old or have parental/guardian consent for this procedure.
*
Confirmed
I acknowledge that I have been informed of the risks associated with body piercing, including infection, allergic reactions, and scarring. I agree to follow all aftercare instructions provided by the studio.
*
Confirmed
I release and hold harmless the studio and its employees from all claims, damages, or injuries that may result from this procedure, except in cases of gross negligence or misconduct.
*
Confirmed
By signing below ,‘I declare that I give my full consent to tattooing/ body piercing being carried out by the aforementioned practitioner. I confirm that potential complications, (eg infection, swelling (for both tattooing and piercing), gum/tooth damage, jewellery migration/embedding) for the procedure undertaken and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it, until the site has healed.I confirm that the above information provided by me for this consent form is correct to thebest of my knowledge, that I am over the age of consent for this procedure (as explained to me by the practitioner) and that I am not currently under the influence of alcohol or drugs.’)
*
Submit Consent Form
Submit Consent Form
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