Client consent form

Complete the sections below. Required fields must be answered before signing.

1. Client information

Legal nameDate of birthEmailPhoneClient photo ID

2. Procedure

ProcedureArtist / piercerBody location

3. Health screening

Are you pregnant or nursing? Yes No

Do you have diabetes, epilepsy, a bleeding disorder, or a heart condition? Yes No

Are you taking blood thinners or other medication that may affect this procedure? Yes No

Do you have allergies or sensitivities to latex, adhesives, metals, pigments, soaps, or antiseptics? Yes No

Do you have a skin condition, infection, rash, or open wound near the procedure area? Yes No

Anything else the artist or piercer should know?

4. Consent, Release & Acknowledgment

I confirm that the information I provided is accurate. I understand the nature and risks of the requested procedure, that results and healing can vary, and that I voluntarily consent to the procedure.

I have read, understand, and agree to the Consent, Release & Acknowledgment.

5. Signature

Client signature — sign with finger or stylus

Client legal nameDate