Consultation Form
Please fill out this form for your virtual piercing consultation/anatomy check.
Contact Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone Call
Text Message
Date of Birth
*
-
Month
-
Day
Year
Date
Piercing/Jewelry?
Which type of piercing are you interested in?
*
Ear Piercing
Nose Piercing
Oral Piercing
Eyebrow Piercing
Navel Piercing
Genital Piercing
Dermal Implant
Other
If you know the exact name of the piercing you want, or if you selected “other”, please type the piercing name here (If getting a dermal put “Dermal”)
Is there a particular type of jewelry that you want for this piercing? (For example: Titanium, gold, stud, hoop, CZ, diamonds, etc)
Photo Upload (Optional)
Browse Files
Drag and drop files here
Choose a file
Attach a photo of your anatomy (location you want pierced) and/or an image of the piercing/jewelry that you want
Cancel
of
Medical Disclosure
This appointment form is for a piercing consultation ONLY. However, full disclosure is required for both consultations and piercing appointments.
Do you have any allergies or medical conditions we should be aware of?
*
Please select any health conditions that apply, then discuss with your artist.
*
Diabetes
Bleeding Disorder
Skin Condition
Latex or Pigment Allergy
Heart Condition
Epilepsy
Communicable Disease
Pregnant/Nursing
Low/High Blood Pressure
Shellfish/Iodine Allergy
None of the above
Please read and agree to each of the following before moving forward. If you have trouble understanding, or questions about anything please let your piercer know so that they can assist you.
*
I certify that I am 18 years of age, or a minor with proper parental consent and documentation.
I understand that there is a possibility of allergic reaction, infection, or health complications.
I agree to follow all instructions regarding the aftercare process of my piercing.
I understand there is a chance I might feel lightheaded, dizzy and/or faint due to my decision to receive a piercing or dermal and will notify my piercer if this happens. Failure to do so releases all piercing artists of any and all responsibility.
I understand it is my responsibility to check placement and approve all aspects to ensure the placement meets my specifications.
I understand there are no refunds once work has been completed.
I understand that the piercer has the right to discontinue service if I become disrespectful, rude, or too difficult to pierce at my own expense.
I hereby release all service providers of all responsibility for services I receive within.
Appointment
Preferred Appointment Date and Time
*
Additional Questions or Concerns
Submit
Should be Empty: