 | ||
Body Piercing Consent Form
If you prefer you can highlight the following text, right click with your mouse button, select all, copy and paste into Word document, print off and bring with you to save you filling this form in at the salon. If you are under 16 however we do need a countersignatory and if they cannot come with you to the salon we need to be able to speak to them on the phone prior to carrying out your piercing and they must be able to confirm certain questions we will ask them about you.
HEALTH QUESTIONNAIRE CONSENT FORM- I hereby declare that I give MAXINE OR LIZ my full consent to pierce me. I have not taken any aspirin or anti-coagulant drugs for the last four hours. 1. Do you/have you ever had any of the following:Epilepsy; Diabetes; Asthma; High Blood Pressure; Heart Disease, Hepatitus, HIV/AIDS; any skin condition (eg. Psoriasis, Cellulitis, Genital Warts etc.) .......Specify what..................................................................... If yes, please specify .....................................then consult your doctor prior to continuing with the piercing. Do you suffer from any allergic responses to adhesive plasters,micropore,creams, metals,etc? Please specifiy ............................................................................................. If you have answered YES to any of the above medical questions, have you consulted with your doctor regarding body piercing? YES/NO Your piercing will be carried out with prior thoroughly sterilised Titanium, which complies with safety standards in a clean and sterile environment, but you must note th e importance of keeping a new piercing 100% clean until completely healed. Do you agree to take precautions, adhere to the Aftercare Instructions given? YES/NO I agree that once I have been pierced it is my sole responsibility and I will follow the advice given, as I understand that a piercing is susceptible to infection until healed. I understand that not all persons can be pierced and that some piercings may grow out. I also understand that if I remove the piercing at some later date some scarring may occur. I here by confirm that the information given by me is true to the best of my knowledge and that I have requested this piercing of my own freewill. I am not under the influence of alcohol or drugs. Name ................................................................................................ Date of Birth ..................................................................................... Address............................................................................................. Signature .......................................................................................... Date .................................................................................................. Site and description of jewellery used at time of piercing ............................................................ (If under 16 years of age, a parent or guardian over must countersign this Consent Form.) Signed by Parent/Guardian .................................................................
|
||