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Piercing Consent Form

Let us do this part
Today's Date:
Tue Apr 29 2025 06:06
Practitioner:*
Body Piercing Location:*
Jewellery Type:*
Please fill in the Piercing Release Form to the best of your ability. If you have any questions please ask a member of staff.
Please read and answer
Y
N
MEDICAL*
Do you suffer from or are you receiving medical guidance for any of the following:
- heart disease
-blood disorders (high/low blood pressure)
- hemophilia
-impetigo
-seizures: I.e: epilepsy
-diabetes
-hepatitis (A,B,C)
- HIV/AIDS
-acne
-psoriasis
-keloid scarring
Details:
 
Y
N
*
Are you on any regular drug treatments?
Please let us know if so
Details:
 
Y
N
*
Pregnant/Breastfeeding?
Any allergies? e.g
Adhesive plasters
Alcohol swabs
Allergies to antiseptic and disinfectant agents such as Chloroxylenol
Jewellery
Metal

Have you applied any topical numbing agents?

Details:
 
Y
N
*
Have you consumed alcohol or drugs in the last 24 hours?
Y
N
EATEN*
Have you eaten a substantial meal or snack in the last 2 hours?
Y
N
*FOR ORAL PIERCINGS ONLY*
Have you had any lip filler in the last 6 months?

I understand that filler can cause piercing migration, and a piercing can cause filler migration.
I understand that filler can cause a piercing to be crooked or too shallow, which can have an effect on the healing
AFTERCARE/DOWNSIZE*
I agree to follow the aftercare routine given to me during my appointment.
I have answered the above information truthfully and to the best of my ability

I confirm that I am aware of the importance of downsizing my jewellery once the initial swelling has subsided, and that there is an additional cost for this. If longer jewellery is not downsized, it can result in the piercing migrating, rejecting or change the angle.

Please be aware that 14ct/18ct gold attachments are still on a titanium labret for initial piercings. If you are wanting a solid 14ct gold labret for your initial piercing, there is an additional cost. You will still require a downsize for an additional cost.

I do not swim regularly and I do not have any holidays or festivals planned during the healing period of my piercing.
LIABILITY RELEASE*
I acknowledge that I have been given adequate opportunity to read and understand this document, that it was not presented to me at the last minute

I understand it is my right to withdraw from the Piercing procedure at any time, however I will not be entitled to a refund once the Piercer has set up, as there are set up costs and piercers time incurred.

I can confirm that I have not applied any topical numbing agents to the Piercing site prior to my appointment. Any such numbing agents used in the Piercing area will result in the piercers refusal to perform the Piercing. I will not be eligible for a refund due to set up costs and piercers time.

I can confirm that I am not under the influence of drugs or alcohol and I give my full consent to be pierced. If we have reason to believe that you are under the influence of drugs or alcohol then we will refuse service, your deposit forfeited and you will be charged the remainder of the service cost.
GDPR*
I understand that my information (data) given on this form will be stored as an electronic copy and will not be stored physically. The information is stored by The Owl and the Pussycat Piercing LTD only and will not be used for marketing purposes or passed on to third parties. By signing our consent form, our clients ackowledge that we are compliant with GDPR regulation and that their information is stored correctly and not passed on
PERMANENT CHANGE*
I acknowledge that the piercing will result in a permanent change to my appearance and that my skin may never return to its pre-piercing condition even after its removal.
Y
N
PHOTOGRAPHY*
I release all rights to any photographs taken of me and my Piercing and give consent in advance for their reproduction in print or electronic form
16+*
I confirm that I am over the age of 16 and will provide my government issued photo identification to a member of staff when asked to prove my age & date of birth.
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.
Legal Name:*
Pronoun:
Chosen name:
Address:*
Postcode:
Date of birth:*
You must be 16 or older
Phone #:*
Email:*
Signature:*