MEDICAL HISTORY
BODY PIERCING CONSENT AND RELEASE FORM
Please check any conditions listed below that apply to you.
| Diabetes | HIV / AIDS | Heart Condition | Faint or Dizzy | ||||
| Epilepsy | Hemophilia | Eczema/Psoriasis | Infections | ||||
| T.B. | Scarring/Keloiding | Herpes | Asthma | ||||
| Hepatitis | Pregnant | Nursing | Blood Thinners |
FILL OUT COMPLETELY (N/A IS NOT AN ANSWER):
How long has it been since you last ate? ____________________________________________________________________
Do you have any allergies? ______________________________________________________________________________
List all medications you are currently taking. _______________________________________________________________
Are there any other known MEDICAL CONDITIONS or CONTAGIOUS DISEASES that may affect your
BODY PIERCING procedure? ___________________________________________________________________________
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PHYSICIAN’S INFORMATION (IF NONE LIST CLOSEST HOSPITAL): Physician’s Name: _____________________________________ Ph # _______________________________ Address___________________________________________ City__________________ State____ Zip_________ |
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I hereby certify that to the best of my knowledge this information is correct.
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All Questions have been answered to my satisfaction.
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I agree to the ARTISTS placement of the said BODY PIERCING.
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This is to certify that I am at LEAST 18 YEARS OF AGE.
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I am not under the influence of ALCOHOL OR DRUGS.
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I understand there is a possibility of an allergic reaction.
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I understand there is a possibility of an infection.
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I agree to follow all instructions concerning the care of my BODY PIERCING.
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I understand that there is a chance I might feel lightheaded, dizzy and/or faint due to my decision to receive a BODY PIERCING.
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I agree to IMMEDIATELY notify the artist in the event I feel lightheaded, dizzy and/or faint before, during or after the procedure. Failure to do so releases BEST TATTOOS, INC. and ARTISTS of all responsibility.
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I hereby release BEST TATTOOS, INC. and ARTISTS of all responsibility for the said BODY PIERCING.
- NO REFUNDS.
CUSTOMER’S INFORMATION (FILL OUT COMPLETELY):
Customer Printed Name: __________________________________________
Customer Signature / Parental Signature____________________________ Date_________ Ph# _____________
Address______________________________________ City______________ State____ Zip_________
Driver’s License #_______________________________ DOB__________________ Age ___________
Race _______________ Sex _______________
Jewelry(Desctiption/Length)_____________________ Placement_______________ Artist___________
Artist Signature ______________________
Emergency Contact _________________________________________ Ph# ______________________
Address______________________________________ City______________ State____ Zip_________
SKIN CONDITIONS / COMPLICATIONS DURING PIERCING: __________________________________
_____________________________________________________________________________________
