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PIERCING CONSENT FORM

First Name*

Last Name*

Phone*

Email*

date of birth

Client stated as above declares the following (check the box if applicable)

THAT I AM CHOOSING THIS PIERCING AFTER THOUGHTFUL CONSIDERATION AND OF MY OWN FREE WILL.

I AM INFORMED ABOUT THE POTENTIAL RISKS OF INFECTION AND OTHER COMPLICATIONS RELATED TO MY PIERCING.

I HAVE RECEIVED WRITTEN INSTRUCTIONS ABOUT THE AFTERCARE OF MY PIERCING.

I CONSIDER MYSELF HEALTHY ENOUGH TO RECEIVE THIS PIERCING.

I AM NOT UNDER THE INFLUENCE OF ALCOHOL OR DRUGS DURING THE PIERCING PROCEDURE.

I AM CURRENTLY NOT TAKING ANY ANTI-BIOTIC OR ANTI-COAGULATION MEDICATION.

I HAVE NOT RECEIVED ANY PLASTIC SURGERY OR RADIOTHERAPY ON THE AREA THAT I WANT TO GET PIERCED IN THE LAST YEAR.

I GIVE CONSENT TO THE PIERCER TO KEEP MY CONSENT FORM ON FILE.

IT IS NOT ADVISED TO GET A PIERCING WHILE BEING PREGNANT OR WHILE STILL BREASTFEEDING BECAUSE OF THE HIGHER CHANCE TO DEVELOP AN INFECTION AND SENSITIVITY TO OTHER COMPLICATIONS.

PLEASE ANSWER THE FOLLOWING QUESTIONS: (CHECK WHAT IS APPLICABLE TO YOU.)

HEMOPHILIA

CHRONIC SKIN DISEASE

CONTACT ALLERGY

DIABETES

SKIN DEFORMITY

SARCOIDOSIS

IMMUNE DISORDER

CARDIOVASCULAR DISEASE

KNOW THAT YOU ARE NOT ADVISED TO RECEIVE A PIERCING IF YOU CHECKED ONE OF THE ABOVE BOXES

I, client as named above, agree with the contents of this consent form. I have filled in this consent form honestly and to the best of my ability

Yes

No

PIERCING TYPE

JEWEL SIZE

NAME BODY PIERCER