Please enable JavaScript in your browser to complete this form.What Piercing are you getting?I acknowledge by filling out this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a piercing and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows: *I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart conditions or take medication which thins the blood. I have informed my piercer of any condition such as diabetes that might hamper healing of the piercing. If I suffer from hepatitis, or any other communicable disease, I have informed the Piercer of this fact and I have been advised of any procedures necessary to promote the satisfactory healing of my piercing. I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing. I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible. I have trustfully represented to the Piercer I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time. I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition. I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and I agree to follow all of them while my piercing is healing. I understand I will be pierced using appropriate instruments and sterilization. I agree to release and forever discharge and hold harmless the Piercer and all employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing. I fully understand THE PIERCING ARTIST DOES NOT ACT AS A MEDICAL PROFESSIONAL. Any suggestions made to me are NOT to be construed as or substituted for advice from a medical professionalDate of Appointment *Name *FirstLastDate of Birth *Address *Phone Number *Email *I confirm that the information given in this form is true, complete and accurate *YesNoPhoneSubmit
