Adult Piercing Consent Form
Ink Imaginarium 26 Herlington PE2 5PN
Client Information
Full Name
*
First Name
Last Name
Age
*
Birth Date
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Phone Number
*
Email
*
example@example.com
Address
*
House Number/Name
Street Name
City
Post code
County
Date of Appointment
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Body Part/s to be pierced
*
e.g. both ear lobes
Name of Body Piercer
*
Hayley
Ani
Pre-Procedure Questionnaire
I confirm I am not under the influence of drugs or alcohol.
*
Yes
Are you pregnant or breast feeding?
*
Yes
No
Are you prone to fainting?
*
Yes
No
Have you consumed any anticoagulants in the last 24 hours? (e.g. blood thinners, large volumes of alcohol, aspirin)
*
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, etc.) If none, please type n/a
*
If yes, please identify the condition and give details of any medication you are taking.
Medical History (e.g. Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc) If none, please type n/a
*
If yes, please identify the condition and give details of any medication you are taking.
Acknowledgment and Waiver
*
I understand that there are known risks associated with body piercing as follows: scarring, blood poisoning (septicaemia), allergic reaction to jewellry, localised swelling, rejection of jewellery. Details of these risks can be found here https://www.healthline.com/health/beauty-skin-care-tattoos-piercings
*
I agree that the body piercer does not have a way of identifying if I am allergic to the elements that will be used for my piercing.
*
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking good care of my piercing and that this is my responsibility.
*
I acknowledge that Ink Imaginarium does not offer refunds.
*
I understand that I need to take care of the piercing by following the instructions given to me at https://inkimaginarium.co.uk/piercings/
*
I hold harmless Ink Imaginarium against any claims, losses, expenses, damages, and liabilities.
I allow my piercing to be photographed and be used for Ink Imaginariums portfolio and social media.
*
I confirm that the information I provided in this document is accurate and true.
I consent to my email address being used for marketing purposes, for example special offers, business updates and events etc. This information will not be sold to thrd parties and will only be used by Ink Imaginarium.
Yes
No
Date of signature
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Client Signature
*
Submit
Should be Empty: