Body Piercing Client Consent Form printable pdf download

Body Piercing

Client Consent Form

Name of Premises:

Address of Premises:

Telephone Number:

Name of Operator:

Name of Client:

Address of Client:

Telephone Number of Client:

Age of Client:

Date of Birth:

Proof of Age of Client and Type of ID used

(attach copy if possible)

Type of jewellery Used:

Site of Procedure (& design if applicable)

FOR CLIENT’S INFORMATION



Scarring



Blood Poisoning (Septicaemia)

Known (potential) risks associated with body piercing



Jewellery Embedding/Migration



Localised Infection- Particularly Nose, Navel, Genitals



Allergic Reactions To Jewellery Metals



Localised Swelling & Trauma Around The Site



Tongue Piercing May Lead To Swelling, Choking &

Restriction Of The Airway

Individual Consent

I declare that I give my full consent to body piercing being carried out by the aforementioned Operator. I confirm that

potential complications, e.g. infection and 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 (i.e. 16 years old) and that I am not currently under

the influence of alcohol or drugs.

Signature of Client:

Date:

Signature of Operator:

Date:

* Please circle as

Appropriate Aftercare Advice Sheet given?

Yes*

No*

appropriate

Parental Consent

(as applicable for piercing)

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 and I understand the

Body Piercing Client Consent Form

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