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Name of Piercer
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Piercing location/locations on body
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Left Ear
Right Ear
Nose
Mouth
Left Eyebrow
Right Eyebrow
Tongue
Chest
Genital
Other
Client Name
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Parent/Guardian's Name
If the client is under the age of 16 years old, this must be filled out.
Date of Birth
Please note, if you look under 25 years old, you will be asked for ID
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Address
Address Line 1
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Address Line 2
City
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Postal Code
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Phone Number
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Email Address
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Have you consumed drugs or alcohol in the last 24 hours?
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Yes
No
Have you eaten in the last 4 hours?
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Yes
No
Medical Information
Please let us know if any of the following applies to you.
Do you have skin complaints (Eczema, Psoriasis, etc)
Do you suffer from any allergies?
Are you prone to fainting attacks / dizziness
Do you take regular medication?
Do you take blood thinning medication or do you suffer from haemophilia?
Could you be pregnant?
Are you breastfeeding?
Do you have any heart complaints or conditions?
Do you have any immune conditions such as HIV, AIDS, or Hepatitis?
Do you have epilepsy, diabetes, or asthma?
Any other associated health conditions that could be contraindicated by the treatment?
If you checked any of the Medical questions, please provide more info
Emergency contact
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Hazards
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I am aware of the potential hazards that may be associated with my piercing and have considered these before giving consent to the procedure(s). I agree to the procedure(s) fully understanding the risks. These include damage to skin tissue and nerves, scar tissue formation, localised swelling, pain and/or discomfort. It can also include allergic reactions, skin infections (such as staph infections), tuberculosis, blood poisoning/septicaemia, and blood-borne diseases (such as hepatitis B, hepatitis C and HIV).
Aftercare
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I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions given to me. I take full responsibility for the healing of my piercing on exit of studio and agree to follow aftercare given to me by my artist after my procedure.
Release
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I agree to waive and release, to the fullest extent permitted by law, the piercer and the studio from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the piecer or the studio, or otherwise.
Duress
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I confirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.
Permanent Change
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I acknowledge a piercing will result in a permanent change to my appearance and may leave permanent scarring even after the piercing is removed.
About this form
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I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract.
Please read carefully
I declare that the above information is true and correct to the best of my knowledge. I am of the required age and able to give full consent for the procedure detailed above. I am not under the influence of drugs or alcohol.
I hereby give consent for the piercer named above to carry out the procedure. I understand the potential risks and complications that are associated with the procedure and confirm that I have been given access to the appropriate aftercare advice. I understand that it is my responsibility to carry out the instructions as suggested by the operator to assist the best possible healing conditions for my piercing.
I consent to photographic images to be taken of my piercing and used for advertising or portfolio purposes on social media/print media by both the studio and the piercer. This may extend to third parties given approval by the studio or the piercer
I understand that the studio has CCTV used solely for the protection of the staff, and clients. Footage will be stored on a secure server for a period of 30 days and will be provided to the police if an incident occurs.
I give consent for the information on this form to be held by the operator and studio for a minimum of two years from the date of the procedure.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Confirmation
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I have read this form carefully and confirm that all of the information is correct to the best of my knowledge
Marketing
Occasionally we would like to send out emails to notify people about promotions, guest artists and cancellations. If you want in, let us know.
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Yes please, email me with awesome offers
No thanks
Submit