Checkbox *

Check box to agree statement is true.

I am not pregnant or nursing. If I have any condition that might affect the healing of this piercing, I will inform my piercer.

I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing.

I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.

I have trustfully represented to the Piercer I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time.

I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition.

I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and I agree to follow all of them while my piercing is healing.

Do you have any additional allergies to items such as metals, soaps, cosmetics or alcohol? *

Yes

No

Are you currently on any medications that might affect the healing of the piercing you wish to receive? *

Yes

No

Do you have any other medical or skin conditions that may affect the outcome of your procedure? *

Yes

No

Do you have any cardiac valve disease? *

Yes

No

Are you currently pregnant? *

Yes

No

Notice *

·Clients who back out of the procedure last minute may be subjected to a $20 set up fee, depending upon the situation. ·All piercings are done with a standard stainless steel jewelry. Other options are available for an additional fee. Please consult with your piercer.

I understand

I have been fully informed of the risks of getting pierced including but not limited to infection, scarring, and latex glove allergy. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I assume any and all risks that may arise from the piercing. *

I still wish to proceed

Name *

First Name

Last Name

Date of Birth *

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Emergency contact (Name and phone #) *

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Today's Date *

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YYYY