Name*
Date of Birth (DD/MM/YYYY)*
Email Address*
Phone*
House Number*
Street*
City*
Post Code*
I give consent to Sophie to carry out my piercing Agree
Any heart condition?* NoYesOther
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
Eaten in the last 4 hours?* NoYes
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 can confirm that I am not taking any medication or suffering from any illness, condition or allergy, which a reasonable person should be aware of, may react adversely to, or be aggravated by piercing. I confirm I have been given aftercare in writing and that it has been explained to me and that I can understand it. I also confirm that I will follow the aftercare procedure until the healing process is complete. I understand that there are associated risks with piercing, which include infection, scarring, allergic reactions and localised swelling. In giving this consent, I release this establishment and it's employees from all liabilities, actions and demands which I may have now or in the future for any loss or damage suffered whatsoever caused as a result of my piercing (except as a result of fraudulent misstatement or in respect of personal injury caused by our own negligence. We DO NOT disclose personal information to third parties! I have read and agreed to the terms of service
Δ
