Child Piercing Consent Form
26 Herlington PE2 5PN
Client Information
Childs Full Name
*
First Name
Last Name
Parents Full Name
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First Name
Last Name
Childs Age
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Childs Date of Birth
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Parents Phone Number
*
Parents Email
*
example@example.com
Parents Address
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House Number/Name
Street Name
City
Post code
County
Date of Appointment
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Name of Body Piercer
*
Hayley
Ani
Body Part/s to be pierced
e.g. left ear lobe
Pre-Procedure Questionnaire
To be completed by parent/guardian for under 16’s
Are you legally able to provide consent for this child to receive a body piercing?
*
Yes
No
Is your child prone to fainting?
*
Yes
No
Has your child consumed any anticoagulants in the last 24 hours? (e.g. blood thinners, 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. https://www.healthline.com/health/beauty-skin-care-tattoos-piercings.
*
The child has expressed their consent for this body piercing to take place.
*
I agree that the body pirecer does not have a way of identifying if I am allergic to the elements that will be used for my child’s piercing.
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I understand that I need to take care of the piercing by following the instructions given to me at https://inkimaginarium.co.uk/piercings/
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I understand that my child might get an infection if I don't follow the instructions given to me in regards of taking good care of my child’s piercing and that this is my responsibility to do so.
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I acknowledge that Ink Imaginarium does not offer refunds.
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I hold harmless Ink Imaginarium against any claims, losses, expenses, damages, and liabilities.
I allow my child’s piercing to be photographed and be used for Ink Imaginariums portfolio and social media.
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I confirm that the information I provided in this document is accurate and true.
*
I understand that children’s ear piercing is payable in full up front and is non-refundable should the child change their mind.
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
Signed Date
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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
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2001
2000
1999
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1997
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1995
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1993
1992
1991
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1989
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1986
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1983
1982
1981
1980
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1978
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1972
1971
1970
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1968
1967
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1963
1962
1961
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Client Signature
*
Submit
Should be Empty: