Piercing Release Release Form

Let us do this part
Today's Date:
Tue Oct 27 2020 02:45
Practioner:*
Piercing Service Consent and Release Form

Please read and answer
 
Student?
 

 
How did you hear about us?
 

 
Piercing Name/Placement on Body*
 

 
Allergies
 

 
Medications
 

 
Medical Conditions
 

Diabetes

Epilepsy

Asthma

Infections

Hemophilia

Blood Thinners

Heart Condiiton

Faint or Dizzy

Immune Condition

Steroid Medication

Psoriasis/Eczema

TB

Scarring/Keloids

Herpes

Hepatitis

HIV/AIDS

Pregnant

Nursing

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.
Personal Info
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.
Legal Name:*
Pronoun:
Prefered name:
Address:*
Date of birth:*
If you are under 18 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


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