←
Body Piercing
Let us do this part
Today's Date:
Wed Nov 27 2024 06:41
Practitioner:*
Body piercing placement:*
Piercing service price:*
Price of jewelry installed in initial piercing:*
Price of additional jewelry purchased:
Description of jewelry installed and purchased:*
Date of procedure:*
Artist signature:*


Thanks for choosing to have your piercing performed by one of the gentle, experienced professionals here at Opal Moon Body Adornments. We only use the best quality jewelry for your new piercing. All initial piercing jewelry is manuactered in the USA from one of the following: implant-grade titanium meeting ASTM F136 or ASTM F1295, niobium, and nickel-free gold of 14k or greater. Your piercer has years of experience and regularly engages in continuing education to ensure you're getting the best, safest, most comfortable piercing we can provide. If you've got any questions, don't hesitate to ask, and congratulations!
Photo ID*
Please take photo(s) of your government issued photo IDs and related paperwork.
Please read and answer
 
How did you hear about us?
 
Y
N
Have you eaten?*
Have you eaten in the past 4 hours? It's a good idea to eat before a piercing to increase your blood sugar levels.
Y
N
Allergies*
Do you have any allergies to products we might use, including medications, metals, skin cleansers, and glove materials? If yes, please provide details.
Details:
 
Y
N
Medical Conditions*
Do you have diabetes, epilepsy, hemophilia, a heart condition or take blood thinning medication? Do you have any other medical or skin condition that may interfere with the procedure or healing of the piercing? Are you the recipient of an organ or bone marrow transplant, or currently taking immune-supressing medications? Are you pregnant or nursing? If I answered Yes to any of the above questions, I have provided further information about my condition.
Details:
 
Risks*
I affirm that I have been fully informed of the risks associated with getting a piercing. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring and keloiding and allergic reactions. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept all risks that may arise from piercing.
Medical advice*
I understand that it is recommended that I speak with a medical professional to better understand the risks of such procedures. By signing this consent, I acknowledge that I have either obtained medical counseling or do not feel the need for such counseling as I understand the risks of the procedure.
Questions*
I affirm that both the Artist and the Piercing Studio have given me the full opportunity to ask any and all questions about the piercing procedure and the they have been answered to my total satisfaction.
Release*
I agree TO WAIVE AND RELEASE to the fullest extent permitted by law each of the Artists and the Piercing Studio from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the Artist or the Piercing Studio, or otherwise.
Aftercare*
I affirm that I have been given verbal and/or written instructions on the care of my piercing while it is healing, and I understand them and will follow them. I acknowledge that it is possible that the piercing can experience complications during healing, particularly if I do not follow the instructions.
Duress*
I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress. I consent to the body piercing procedure and to any action or conduct reasonably necessary to perform the procedure.
Permanent change*
I acknowledge that the piercing will result in a permanent change to my appearance and that my skin may not be restored to its pre-piercing condition even after its removal.
This Document*
I acknowledge that I have been given adequate opportunity to read and understand this document, and I understand that I am signing a legal contract. I have completed the Body Piercing Consent for truthfully and accurately.
Environmental Concerns*
I understand that for more information I may contact the Florida Department of Health Division of Envionmental Health at 850-245-4277 regarding environmental concerns
Photography
I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form.
If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.
Client Information
I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.
Legal Name:*
Chosen name:
Address:*
Postcode:
Date of birth:*
If you are under 18 your parent/guardian will be required
Gender:
Nationality:
Phone #:*
Email:*
Signature:*


Emergency Contact
If something happens, your emergency contact might need to explain your medical history, allergies, or medications.
Name:
Phone #:*
Address:
Physician Information
Enter your physician or medical practitioner's contact details or use our suggested default medical facility.
Name:
Contact:
Address: