Piercing Consent Form Piercing Consent Form 1Client Details2Medical History3Declaration Client DetailsClient NameEmail PhoneDOB and AgeAddressType Of PiercingSelect an optionEarFacialBodyOralPrevious PiercingsHave you had a piercing at the same site before? Yes No If yes, please give details:(Required) Medical HistoryImportant: If you are unsure whether a piercing is safe for you, please seek medical advice before proceeding. Heart ConditionsDo you have any heart‑related medical conditions? (Examples: prosthetic heart valve, heart valve disease, angina, high or low blood pressure) Yes No Please provide details:(Required)Bleeding or Clotting DisordersDo you have hemophilia or any other bleeding/clotting disorder? Yes No Please provide details:(Required)EpilepsyDo you have epilepsy? If yes, how is it managed or controlled? Yes No Please provide details:(Required)Blood‑Borne VirusesHave you ever been diagnosed with any blood‑borne virus? (Examples: Hepatitis B, Hepatitis C, Hepatitis D, HIV) Yes No Please provide details:(Required)Autoimmune or Metabolic ConditionsDo you have diabetes or lupus? Yes No Please provide details:(Required)Skin Conditions or Healing IssuesHave you experienced any problems with skin healing in the past? (Examples: psoriasis, eczema, slow healing) Yes No Please provide details:(Required)Keloid or Raised ScarringDo you form raised, thick, or “lumpy” scars (keloid scars)? Yes No Please provide details:(Required)Allergies (Piercing‑Specific)Do you have any known allergies or allergic reactions to any of the following? e.g Plasters/ Creams/ Metals/ Iodine/ Shellfish/ Latex/ Food allergies/ Other Yes No Please provide details:(Required)Prescribed MedicationsDo you take any regular prescribed medication? e.g. Warfarin, high‑dose aspirin Yes No Please provide details:(Required)PregnancyAre you currently pregnant? Yes No Please provide details:(Required)FaintingAre you prone to fainting episodes or dizziness? Yes No Please give the reason if known:(Required) Client DeclarationClient Declaration(Required) I declare that I give my full consent for a body piercing to be carried out by my practitioner. I confirm that I understand the potential complications of the procedure (including infection, swelling, gum/tooth damage, jewellery migration, and embedding). The aftercare instructions have been explained to me in full. I have received an aftercare advice sheet containing more detailed information, and I agree that it is my responsibility to read and follow these instructions until the piercing site has healed. I confirm that the information I have provided in this consent form is accurate to the best of my knowledge. I confirm that I am over the legal age of consent for this procedure (as explained by the practitioner) and that I am not currently under the influence of alcohol or drugs.Client Declaration(Required) I confirm that i have read and understand the aftercare instructions related to my piercing choice.Name of Client (Print)Signature(Required)
