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Body Modification Consent

Let us do this part
Today's Date:
Wed Dec 31 2025 12:20
Practitioner:*
Piercing Location on Body:*
Piercing Name/Type:*
Piercing Cost $$:*
Jewelry- size, type/style, expiration date:*
Needle(s)-size, brand/make, batch and/or lot #, expiration date?:*
Artist signature:*


Please read and answer
Release *
I authorize Reverie Tattoo & Piercing to modify my body. I hereby agree to hold harmless Reverie Tattoo & Piercings and its officers directors, from all manners or liability claims actions and demands, in law or equity, which I or my heirs have or might have now or hereafter or by reason of complying with my request to have a body modification performed.
Consent*
I fully understand that any employee or agent of Reverie Tattoo & Piercing, when performing the body modification is not acting in capacity of a medical professional of Nevada. The suggestions made by the Piercer of Reverie tattoo are only suggestions. They are not to be construed or substitute as advice from a medical professional.
Proper Healing*
I agree to follow the suggestions outline in the written body modification aftercare instructions provided to me until healing is complete. I understand that any type of body modification may take anywhere from 4 to 24 months or more to heal and may be susceptible to rejection and or action by my skin out anytime by no fault of mine or my operator.
Body Modification Instructions *
I have read the body modification aftercare instructions or the instructions have been fully read to me. I understand the entirety of the aftercare instructions and I hereby assume full responsibility and consequences of this procedure, the after care and maintaining the cleanliness of the modified area. I understand that I am making an informed permanent change to my body and no claims have been made regarding the ability to undo the changes.
Y
N
Eaten*
Have you had anything to eat or drink in the last four hours? *You must eat and be hydrated before receiving a piercing.
Y
N
Under the influence *
Are you under the influence of drugs or alcohol?
Details:
 
Y
N
Existing conditions*
Are you prone to bleeding or hemophilia? Fainting, epilepsy, a history of seizure, narcolepsy, or other conditions that could interfere with the body art procedure?
Details:
 
Y
N
*
Do you take antibiotics before any dental procedures?
Y
N
Previous 24 Hr prior*
Have you taken aspirin, ibuprofen, or prescription blood thinners in the last 24 hours? Have you ingested anticoagulants (such as heparin or warfarin), antiplatelet drugs, or non-steroidal anti-inflammatory drugs (NSAIDS) (such as aspirin, ibuprofen,
etc.) in the last 24 hours?
Details:
 
Y
N
Allergies *
Do you have an allergy to latex? Metal allergies? Iodine, or other such products?
Y
N
Pregnant*
Are you pregnant or breast-feeding?
Y
N
*
Are you under the care of a physician?
Details:
 
Y
N
Irritation *
Do you have any irritation, discoloration, swelling or lumps near the site to be modified?
Details:
 
Y
N
Risks?*
Do you have any condition that would make this procedure a risk to your health?
Details:
 
 
*
How did you hear about us?
 
Y
N
Meds?*
Have you ingested any medication that can inhibit the
ability to heal a skin wound?
Details:
 
Y
N
Skin conditions?*
Do you have a history of skin diseases that might inhibit
the healing of the body art procedure?
Details:
 
Y
N
Communicable Diseases?*
Do you have any communicable diseases (i.e., hepatitis
A, hepatitis B, HIV, or any other disease that could be
transmitted to another person during the procedure)?
Details:
 
Y
N
Other Conditions?*
Do you have diabetes, high blood pressure, heart
condition, heart disease, or any other conditions that could
interfere with the body piercing procedure?
Details:
 
Y
N
High Quality Jewelry*
I understand that my piercer uses ONLY Titanium Jewelry for my piercing. Which is industry standard as premium Jewelry.
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
Phone #:*
Email:*
Signature:*


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