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Piercer Name and Piercing Name

Today's Date:

Wed Mar 18 2026 12:38

Practitioner:*

Piercing Procedure Name(s) (i.e., Nostril, Lobes, Navel, etc.):*

Location(s) on the body:*

Jewelry Style(s) and Size(s):

Primitive Accents Body Piercing

Please read and answer

Risks*

I have been fully informed of the risks associated with getting a piercing. I understand that these risks can lead to injury or adverse effects, including but not limited to:

-Swelling, bruising, discomfort, bleeding, and/or pain.
-Allergic reactions.
-Irreversible changes to the human body.
-Infections
-Removal of the piercing may leave permanent scarring and disfigurement.

I still wish to proceed and I freely accept all risks that may arise from getting pierced today.

Have you Eaten in the past 4 hours?*

Getting pierced on an empty stomach may cause a drop in blood sugar levels which can lead to dizziness and/or fainting.

Duress*

I affirm that I am not under the influence of alcohol or drugs, and that I am not being forced to get pierced against my will. I am getting pierced today of my own volition.

Have you taken anticoagulants in the last 24 hours?*

Have you ingested anticoagulants (such as Heparin or Warfarin). antipatelet drugs, or non-steroidal ant-inflamatory drugs (NSAIDS, such as aspirin, ibuprofen, etc.) in the last 24 hours?

Details:

Medication*

Do you take any medication that can inhibit the ability to heal a skin wound?

Details:

Allergies*

Do you have any allergies or adverse reactions to latex or iodine?

Details:

Medical Conditions*

Do you have any of the following medical conditions that may interfere with the piercing procedure or inhibit the healing of the piercing? Such as:

-Hemophilia, epilepsy, a history of seizures, fainting, or narcolepsy
-A history of skin disease
-Diabetes, high blood pressure, heart condition, or heart disease
-Communicable diseases (i.e., Hepatitis A, Hepatitis B, AIDS, HIV, or any other disease that could be transferred to another person during the procedure)

Details:

This Document*

I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute, and I understand that I am signing a legal contract.

Questions*

I affirm that the Artist and the Piercing Studio have given me the full opportunity to ask any and all questions about the piercing procedure and they have been answered to my total satisfaction.

Aftercare*

I affirm that I have been given aftercare instructions for my new piercing to ensure a smooth healing process.

I understand these instructions and agree to follow them. If I have any questions or concerns during the healing process, I agree to contact the Artist or Piercing Studio for additional assistance.

I acknowledge that it is possible for the piercing to become infected, particularly if I do not follow the proper aftercare procedures.

Release*

I AGREE TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Piercing Studio from all liability for any and all claims or causes of action that I, my estate, heirs, executors or assignees may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the Artist or the Piercing Studio, or otherwise.

For comments and/or complaints - contact the Southern Nevada Health District, Environmental Health Division. (702) 759-0677 or send written comments to Post Office Box 3902, Las Vegas, NV 89127

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.

Legal Name:*

Pronouns:

Chosen name:

Address:*

Postcode:*

Date of birth:*

If you are under 18 your parent/guardian will be required

Age:

Gender:

Phone #:*

Email:*

Signature:*

Sign or type signature:

Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

Phone #:

Photo Identification *

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