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Piercing Release Form

Let us do this part
Today's Date:
Fri Apr 26 2024 11:28
Practitioner:*
Body Part Being Pierced :*
Please read and answer
 
Physician Name and Phone Number*
 
 
Physician Address*
 
 
Emergency Contact info - Name, Phone Number, Address*
 
 
List any allergies you have, including to medications. *
 
Y
N
Do you have a history of Bleeding Disorders?*
Aftercare *
Prior to my Piercing, I received verbal and written information about the following and discussed it with my piercer or the establishment operator : 1) A brief description of my piercing procedure; 2) Any precautions for me to take before my piercing; 3) A description of the risks and possible consequences of my body piercing; 4) Instructions for care and restrictions following my piercing; and 5) Restrictions against piercing minors.
Complications
Description of Complications during proceedure.
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.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Name:*
Address:
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Gender:
Nationality:
Phone #:*
Email:*
Signature:*


Photo ID
Please take photo(s) of your government issued photo IDs and related paperwork.