Body Piercing - English
Ask a staff member what to enter
Today's Date:
Sat May 4 2024 12:22
Body piercing name or body part:*
Please read and answer
Y
N
Do you have flu like symptoms?*
IF YOU HAVE MORE THAN ONE OF:
- a fever
- shortness of breath
- sore throat
- hoarse voice
- difficulty swallowing
- new smell or taste disorder(s)
- nausea
- diarrhea
- abdominal pain
- unexplained fatigue/malaise
- chills

YOU NEED TO NOTIFY A STAFF MEMBER IMMEDIATELY.
COVID-19*
I currently have no symptoms of COVID-19 and I am not awaiting test results.
 
How did you hear about us?*
Google, friend, Facebook, Facebook mothers' group, Instagram, etc.
 
Y
N
Eaten*
Have you eaten in the past 4 hours?
Y
N
Latex Allergy*
Do you have a latex allergy?
Details:
 
Y
N
Heart disease*
Do you have heart disease?
Y
N
Allergies*
Do you have or have you had allergies to nitrile, metal, chlorhexidine gluconate, isopropyl alcohol, iodine? If yes, please provide details.
Details:
 
Y
N
Convulsions*
Do you have or have you had convulsions? (ie. epilepsy)
Y
N
Hemophilia*
Do you have hemophilia?
Y
N
Bruise easily*
Do you bruise easily?
Y
N
Diabetes*
Do you have diabetes ?
Y
N
Blood pressure*
Do you have low or high blood pressure?
Details:
 
Y
N
Immunodeficiency syndrome*
If you have been diagnosed with an immunodeficiency syndrome or bloodborne disease that could affect the healing of your piercing, please check yes and discuss with your piercer as we want to ensure that you are in good health to heal the piercing.
Details:
 
Y
N
Additional health conditions*
Do you have additional health conditions to those mentioned above that may interfere with the healing of the piercing?
Details:
 
Y
N
Blood thinners*
Have you taken any blood thinning medications in the last 24 hours?
Y
N
Previous negative experiences *
Have you had previous negative experiences with piercing/ tattooing/ blood extraction/ vaccination?
Details:
 
Y
N
Drugs*
Have you taken any recreational drugs or psychoactive substances in the last 48 hours?
Details:
 
Y
N
Alcohol*
Have you consumed alcohol in the Last 24 Hours?
Details:
 
Y
N
Dizzy spells*
Are you subject to dizzy spells?
Y
N
Fainting*
Are you subject to fainting?
Y
N
Pregnant*
Are you pregnant?
Y
N
Breastfeeding*
Are you breastfeeding?
Y
N
Photo*
I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form.
Aftercare*
I affirm that I received instructions on the care of my piercing and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions.
Permanent change*
I acknowledge that the piercing will result in a permanent change to my appearance and that my skin may not be restored to its previous condition even after its removal.
Risks*
I understand that the risks associated with getting a piercing, known and unknown, can lead to injury including, but not limited to, infection, scarring, and allergic reactions. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept all risks that may arise from piercing.
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.
Declaration*
I solemnly declare that the information I have given on this CONSENT FORM and in the MEDICAL HISTORY is true. I confirm that I am not under the influence of psychoactive substances or alcohol and that I am of sound mind in choosing to have my body pierced by Mauve. I assume full responsibility for the care of my body piercing in the minutes and hours following my body piercing procedure in the manner described to me . In giving my written consent, I release Mauve and the piercer from all responsibility or liability on my part, for any and all injury or side effects related to my body piercing.

By signing below I confirm that I have been advised of the studio policy that if I change my mind and do not get the piercing that I will forfeit my deposit and be required to pay a fee of $50 per scheduled piercing to cover incidental costs incurred by the studio and I agree to pay this if this occurs.
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:*
Pronoun:
Chosen name:
Address:
Postcode:
Date of birth:*
If you are under 16 your parent/guardian will be required
Phone #:*
Email:*
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.