Piercing Client Consent Form

Email *

Password*

Please set a password so that you can download the form after completion. Confirm Password*

Send copy to email address

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Client Details

First Name *

Last Name *

Date of Birth *

Current Age: *

ID Type: *

Passport Driving License National ID Card Other Parental Consent

If Other, please specify:

Copy of ID:

Please upload a clear image of your ID.

Email *

Mobile *

General Consultation

Have you had any alcohol, aspirin or any other medication (prescribed or non-prescribed) in the last 24 hours? *

Please specify:

Have you eaten a meal in the last 4 hours? *

Do you suffer from dizzy or faint spells, or have you ever fainted? *

Are you pregnant or breastfeeding? *

Yes No

Do you suffer from any skin conditions? *

e.g. eczema, acne, dermatitis, cellulitis, impetigo, warts or any other condition

Please specify:

Do you suffer from any medical conditions? *

e.g haemophilia, high blood pressure, diabetes, epilepsy, asthma, heart problems or any other condition?

Please specify:

To your knowledge do you suffer from any of the following conditions: Hepatitis B or C infection, HIV infection? *

Please specify:

Do you have any allergies/intolerances? *

Please specify:

Piercing

Date: *

Piercing Type(s): *

Belly Eyebrow Lip Nipple Nose Septum Tongue Other

If Other, please specify:

Price Quoted: *

Consent

I agree that the information provided is true and to the best of my knowledge. I have discussed all aspects of the procedure (colour, placement, design, jewellery etc.) with the technician and I am happy with what has been discussed. I understand that the final outcome of the procedure cannot be guaranteed and may vary depending on skin type and after-care. I understand that the care of the treated area is my responsibility and is very important to prevent infection and to encourage rapid healing. I agree that the procedure will be conducted in sterile conditions and all materials will be sterile and pre-packaged where appropriate.

Signed: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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