Piercing Consent Form

Before we can sit you down in a chair, we just need to do a little record keeping. Lets start with the name of the piercer with whom you have a booking.

Piercer

First Name

Last Name

Phone

Email

Address

City

State/Province

Zip/Postal

Age

Drivers License or I.D.

Maximum upload size: 10MB

Birth Certificate (Under Age Clients)

Maximum upload size: 10MB

I acknowledge by signing this release that I have been given full opportunity to ask all questions that I may have about obtaining a piercing from Kita / Tylor and all my questions have been answered to my full and total satisfaction. I acknowledge that services are non-refundable, and I have been advised of the matter set forth and agree as follows

#1

I am not pregnant or nursing. I do not have epilepsy or haemophilia. I do not suffer from any heart condition or take medications which thins the blood. I have informed my piercer of any medical conditions I have that might compromise healing or the piercing process.

#2

If I suffer from hepatitis or any other communicable disease, I have informed my piercer of this fact and I have been advised of any necessary procedure to promote a satisfactory healing process.

#3

I do not suffer from any medical or skin conditions such as but not limited to: keloids or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the side of the piercing.

#4

I have advised my piercer of any allergies to Metals, latex, soaps, vitamins, adhesives, or medications. I acknowledge it is not responsibly possible for the piercer to determine whether I might have an allergic reaction to the piercing process involved in the piercing and further acknowledge that such a reaction is possible.

#5

I have trustfully represented my piercer, I am 18 years or older. I’m not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time.

#6

I acknowledge obtaining this piercing was my choice alone and result in a semi permanent alteration to my body and that the removal of the piercing could potentially cause scarring and the possibility of the skin not returning to pre piercing condition. I acknowledge that the piercing procedure is non-refundable and once pierced I legally must pay for the services rendered.

#7

I acknowledge infection is as a result of obtaining a piercing. I have received after care instructions and agree to follow all of them during the healing process to ensure proper healing and the least possible chance of infection.

#8

I understand that I will be pierced using appropriate sterilized instruments and equipment.

Therefore, I request a piercer to pierce my

I agreed to release and forever discharge and hold harmless the piercer and all my employees from any and all claims, damaged or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used by my piercing.

Client Signature

Clear

Date

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Piercing Information

Equipment Lot #

Equipment Exp. Date

Needle Lot #

Needle Exp. Date