piercing consent
CLIENT DETAILS
Name
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First
Last
Preferred Name
Date of Birth
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Email
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Phone
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Drivers License Number
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Licence Expiry Date
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CLIENT DETAILS
Please select 'yes' or 'no' to the following if they apply to you. Please note that answering ‘yes’ to any of these questions does not necessarily exclude you from receiving a tattoo
Cancer
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Yes
No
Diabetes
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Yes
No
Bruising or swelling
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Yes
No
Blood thinners or Pain medication
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Yes
No
HIV/AIDS or any other blood borne diseases
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Yes
No
Prone to bleeding or high/low blood pressure
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Yes
No
Hepatitis
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Yes
No
Are you under the influence or drugs or alcohol?
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Yes
No
Are you pregnant or breastfeeding
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Yes
No
Latex allergy
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Yes
No
Other allergy
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Yes
No
Prone to fainting
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Yes
No
I acknowledge by signing this consent form that I have read and agree to the following:
(1) I will tell the piercer prior to the procedure if I have diabetes, epilepsy, hepatitis, HIV, AIDS or any communicable disease.
(2) I do not have any medical or skin conditions such as but not limited to: acne, scarring (Keloid), eczema, psoriasis, moles or sunburn in the area to be pierced that may interfere with the piercing. If I have any type of infection or rash anywhere on my body, I will advise my piercer.
(3) I acknowledge that it is not reasonably possible for the representatives and employees of Inklaid Tattoo to determine whether I might have an allergic reaction to the jewellery used in my piercing, and I agree to accept the risk that such an allergic reaction is possible.
(4) I acknowledge that infection is always possible as a result of obtaining a piercing, particularly in the event that I do not take proper care of my piercing.
(5) I understand my jewelry will be inserted or removed using appropriate instruments and techniques. I willingly submit to these procedures, with a full understanding of possible complications such as, but not limited to, infection, allergic reaction or rejection of the piercing.
(6) I understand that any employee or agent of Inklaid Tattoo when performing a jewellery insertion, removal, assessment or stretching does not act in the capacity of a medical professional. The suggestions made by any employee or agent of Inklaid tattoo are just suggestions. They are not to be construed or substituted for advice from a medical professional.
(7) I understand that sterilized jewellery and equipment and/or single use disposables will be used for my piercing
(8) I understand that by having this piercing performed that I am making a permanent change to my body and no claims have been made regarding the ability to undo the changes made.
(9) I accept to release and forever discharge the employees and representatives of Inklaid from any and all claims, damages and legal actions arising from or connected in any way with my piercing and of the procedures and conduct used to apply my piercing.
(10) I have received verbal aftercare instructions which I fully understand and I hereby assume full responsibility for aftercare and cleanliness.
(11) I acknowledge that the information on this form is true and correct.
Signature
*
X
Todays Date
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