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.I acknowledge and accept the following informationJEWELLERY CARE & RESPONSIBILITY(Required) All jewellery is securely fitted and checked by your piercer before you leave the studio. You will be advised at your appointment that jewellery can naturally loosen over time and should be checked and tightened regularly. Once you leave the studio, it is your responsibility to regularly check that your jewellery remains secure. We cannot accept responsibility for jewellery that becomes loose or is lost after your appointment.Name of Client (Print)Signature(Required)Your NameYour NameYour NameYour NameUntitled First Choice Second Choice Third Choice Consent I agree to the privacy policy.
