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Piercing Release English

Let us do this part
Today's Date:
Fri May 2 2025 06:32
Practitioner:*
Piercing Service Consent and Release Form

Please read and answer
*
I understand that body piercing is an invasive procedure. The risks include but are not limited to: Allergic Reaction, bleeding, scarring, keloids, nerve damage, bacterial infection, viral infection, migration, or rejection of jewelry
 
Chosen Name if Different from Legal Name
 
 
Minor Piercing Agreement
If this piercing is for a minor, you need to submit GOVERNMENT ISSUED ID for both PARENT/GUARDIAN and MINOR. For the minor, birth certificates, state IDs, passports, tribal, or military IDs will suffice. If using a birth certificate as identification for the minor, please also provide photo ID. If using a birth certificate, a school ID will suffice as photo ID.

If you do not submit proper identification we may have to reschedule your appointment.

If this piercing is for a minor, please complete the form with the MINOR's information, NOT PARENT/GUARDIANS. Once you have completed the form and entered the minor's birthdate, a parental consent section with pop up for the parent to fill out and sign.


Please list the IDs you will be providing for the minor in the space below.

THEN submit pictures of them at the bottom of the form.
 
 
How did you hear about us? -OPTIONAL
 
 
Piercing Name/Placement on Body -REQUIRED*
 
Y
N
Bloodborne Pathogens*
Do you have any bloodborne pathogens, transmittable diseases, or recent illnesses? If so, please advise your piercer
Health*
I do not currently have diabetes, epilepsy, hemophilia, a heart condition, nor am I on blood thinning medication. I am not the recipient of a recent transplant. I am not pregnant or nursing. I do not have a mental impairment that may affect my judgement in getting the piercing.

OR if any of these conditions apply to me, I have disclosed them to my piercer and discussed the additional effects to my piercing they may have.
Influence*
I am not under the influence of alcohol or drugs, and am consenting to be pierced without duress or coercion.
Positive responses to any of these questions will likely indicate a deeper discussion with your artist before proceeding with your body modification
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:*
Pronoun:
Address:*
Postcode:
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.