Art On Skin Piercing Consent Form (ages 6-15)

Legal Name of Piercee*

First NameLast Name

Preferred name

Preferred Pronouns*

She/HerHe/HimThey/Them

Date of Birth*

Date

Phone Number*

Area CodePhone Number

Email*

example@example.com

In the past 7 days have you felt unwell or had any symptoms of Covid-19 (such as fever, coughing, shortness of breath), returned from overseas, had any contact with a confirmed or suspected case of Covid-19?*

YESNO

Have you eaten in the last 4 hours?*

YESNO

Do you take, or have plans to take any acne medication such as Accutane, Roaccutane etc?

YESNOStopped this medication within the prior three months.

Have you consumed alcohol in the last 8 hours?*

YESNO

Are you under the influence of drugs?*

YESNO

Have you taken aspirin, ibuprofen or blood thinners in the last 24 hours?*

YESNO

Are you prone to heavy bleeding?*

YESNO

Are you pregnant or breastfeeding?*

YESNOGave birth within the prior three months

Are you prone to fainting?*

YESNO

I understand that sterilized jewellery and equipment and/or single use disposables will be used for my piercing.*

YES

Do you have any allergies?*

write 'no' if no allergies

How did you hear about us?

I consent to having my piercing photographed/filmed for promotional/educational purposes (optional)

YES PhotographedYES FilmedNO PhotographedNO Filmed

Parent/Guardian please upload a photo of your proof of ID. The piercee's ID will be visually sighted, please have this prepared.*

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Drivers Licence, Proof of Age or Passport - Please block out Licence/Passport Number/Card Number before submitting. Please see our privacy policy here https://artonskin.com.au/privacy

Parent/Guardian please upload a photo of your proof of relationship e.g. birth certificate or medicare card*

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Please block out the Card Number before submitting. Please see our privacy policy here https://artonskin.com.au/privacy

I acknowledge by signing this consent form that I have read and agree to the following:

(1) I do not have diabetes, epilepsy, hepatitis, HIV, AIDS or any other communicable disease.

(2) I do not have any medical or skin conditions such as but not limited to: acne, scarring (Keloid), eczema, psoriasis, moles or sunburn in the area to be pierced that may interfere with the piercing. If I have any type of infection or rash anywhere on my body, I will advise my piercer.

(3) I acknowledge that it is not reasonably possible for the representatives and employees of Art On Skin to determine whether I might have an allergic reaction to the jewellery used in my piercing, and I agree to accept the risk that such an allergic reaction is possible.

(4) I acknowledge that infection is always possible as a result of obtaining a piercing, particularly in the event that I do not take proper care of my piercing.

(5) I understand my jewelry will be inserted or removed using appropriate instruments and techniques. I willingly submit to these procedures, with a full understanding of possible complications such as, but not limited to, infection, allergic reaction or rejection of the piercing.

(6) I understand that any employee or agent of Art On Skin when performing a jewellery insertion, removal, assessment or stretching does not act in the capacity of a medical professional. The suggestions made by any employee or agent of Art On Skin are just suggestions. They are not to be construed or substituted for advice from a medical professional.

(7) I understand that my piercing will be stretched only one size at a time (no more than one gauge or afew millimetres at a time) using no flare or single flare jewellery only (double flare not allowed)

(8) I understand that by having this piercing performed that I am making a permanent change to my body and no claims have been made regarding the ability to undo the changes made.

(9) I accept to release and forever discharge the employees and representatives of Art On Skin from any and all claims, damages and legal actions arising from or connected in any way with my piercing and of the procedures and conduct used to apply my piercing.

(10) I have received verbal aftercare instructions which I fully understand and I hereby assume full responsibility for aftercare and cleanliness.

(11) I acknowledge that the information on this form is true and correct.

I release all rights to any photographs taken of me and the piercing and give consent in advance to the reproduction in print or electronic form. I acknowledge that I had the opportunity to ask questions regarding this procedure and all questions were answered to my satisfaction.

I understand that taking photos and or videos in the piercing room is not permitted.

YES

Signature of Minor*

Name of Parent/Guardian*

First NameLast Name

Signature of Parent/Guardian*

Date*

Time of your appointment*

:HourMinutesAM/PM Option

The piercee's ID will be visually sighted, please have this ready. Examples of ID for minors include passport, photo card, student ID, or if too young for these, a copy of their birth certificate.

MINORS AGED 6-15 YEARS PIERCING CONSENT FORM