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Piercing Consent form

Personal information

Date of birth
Day
Month
Year

Piercing information

Date of piercing
Day
Month
Year

Medical questions

Suffers from any heart conditions (e.g prosthetic heart valve/heart valve disease/angina/blood pressure problems)?
Yes
No
Suffers from any known blood borne virus (e.g Hep B, Hep C, Hep D, HIV)?
Yes
No
Suffers from haemophilia/other clotting disorders?
Yes
No
Suffers from epilepsy? If yes, how is it controlled?
Yes
No
Suffers from diabetes or lupus?
Yes
No
Suffers from any problems with skin healing e.g psoriasis, eczema?
Yes
No
Suffers from any raised scars (keloid scars)?
Yes
No
Suffers from any known allergic responses e.g plasters/creams/metals/iodine/shellfish/latex/foodstuffs/other? (Please indicate)
Yes
No
Takes any prescribed medication regularly (especially any anticoagulants such as Warfarin or high dose aspirin or any immune-suppressants such as steroids?
Yes
No
Pregnant (immune response affected by pregnancy and any infection may affect the unborn child)
Yes
No
Nursing mother (risk of infection can be risk to the baby)
Yes
No
Prone to fainting attacks?
Yes
No
Any previous piercings at proposed site?
Yes
No

Please note: Treatment cannot be undertaken if you are under the influence of drugs or alcohol

Declaration

 ‘I declare that I give my full consent to  body piercing being carried out by the aforementioned practitioner. I confirm that potential complications, (eg infection, swelling, gum/tooth damage, jewellery migration/embedding) for the procedure undertaken and aftercare instructions have been explained to me. A written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it, until the site has healed.

I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (as explained to me by the practitioner) and that I am not currently under the influence of alcohol or drugs.’

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Parental Consent (If applicable)

Parent's Date Of Birth
Day
Month
Year

‘I consent that all of the intended procedure has been explained to me and that the information provided by me is correct to the best of my knowledge. I hereby consent to my child (named above) having the body piercing’

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