Name*
Date of Birth (DD/MM/YYYY)*
Email Address*
Phone*
Street*
City*
Post Code*
I give consent to Sian to carry out my piercing Agree
Haemophilia?* NoYes
Haemorrhaging / bruise easily?* NoYes
HIV / HEP A B C D etc?* NoYes
High blood pressure?* NoYes
Diabetes?* NoYes
Reaction to skin care products/moisturisers/soap/creams?* NoYesOther
Slept well in the last 24 hours?* NoYes
Are you pregnant?* NoYes
Have you taken any blood thinning medication?* NoYes
Are you prone to fainting or dizziness?* NoYes
Have you taken any drugs or consumed alcohol in the past 24 hours?* NoYes
If you are under the age of 18, you will need parental consent to continue with the piercing. Please gain consent from your parents and get them to put their signature in the box below. I give my child permission to receive a piercing
I have read and agreed to the terms of service
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