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Body Piercing Authorisation

Let us do this part
Today's Date:
Thu Jul 17 2025 06:12
Practitioner:*
:
******IMPORTANT INFORMATION*****

You MUST attend your appointment alone. No friends or family permitted, including children. You may be asked to reschedule if you bring a child with you - unless it is their appointment.

Minors (11-18 years) must be escorted by their parent.

Please come to your appointment on time - if you are too early you may not be able to wait inside. If you are late, you may be asked to reschedule your appointment.

If you experience any covid symptoms (or any other illness!) prior to your appointment, PLEASE contact us to reschedule.

Please fill this form out to the best of your knowledge - it is here to keep you, and me safe at your appointment. Please complete it fully - failure in doing so may mean in the last minute cancellation of your precious appointment.
Please read and answer
 
Type of Piercing*
1 x lobe 2 x lobes Helix Tragus Anti Tragus Daith Rook Snug Conch Nose Septum Navel 1 x nipple 2 x nipples Eyebrow Upper Mouth (unavailable) Lower Mouth (unavailable) Lip (unavailable) Philtrum (unavailable) Tongue (unavailable) Micro Dermal Surface Piercing Industrial Tongue Web (unavailable) Smiley (unavailable) Undecided piercing x1 Undecided piercing x 2 Undecided piercing x 3 Other
 
If you put 'other' please state here
 
 
Are you currently pregnant?*
Yes No
 
Are you suffering from any of the following?*
Heart disease Haemorrhaging Hepatitis B or C Eczema Epilepsy Impetigo Diabetes Fainting HIV Common Allergies (pollen/dust) Common Allergies (metals) Covid symptoms None :D
 
Are you taking any medications that I need to be aware of for your piercing safety?*
 
Your piercing service will be carried out using sterilised equipment and jewellery - it is up to you to keep the area clean after you leave. After-care is simple - touch the area as little as possible, and clean once a day only with fresh warm water.

I declare that I have read the above information and fully understand it. I agree to the piercing procedure as stated above. I fully realise that my piercer cannot be held responsible for the way in which I treat the piercing once I have left the premises. Please note that it is not possible to give blood for 3 months after a piercing. I am over 16 years of age.
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:
Phone #:*
Email:
Signature:*