Adult Service Appointment Request Form

I voluntarily give my full consent to body piercings, tooth gems, and other services carried out by the practitioner. I am informed about possible side effects and complications of body piercing and tooth gem procedures such as infection, swelling, rejection, and enamel decay. I understand and agree that it is my responsibility to read and follow the instructions about procedures and aftercare.

I confirm that the information that I provide in this consent form is complete and accurate.

Please acknowledge the following items:

Client Name

Legal First NamePreferred Name (if applicable)Legal Last Name

Pronouns

Other

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Please select the conditions you have:

Appointment Date

Please select the service(s) you are requesting an appointment for.

**Please Note**

All piercing and tooth gem prices vary depending on what piercing it is and what jewelry or gems are selected. All service prices are listed on my instagram. If you have any other questions feel free to message my instagram or send me an email.

Based on the service(s) selected above, please briefly describe exactly what you’re requesting. (Ex: Double lobe piercings or 3 tooth gems.)

Client Signature

Signed Date

Date

Appointment Request Form

Client Information

Photo Release Consent Form