Body Piercing Medical History Consent And Release Form printable pdf download

BODY PIERCING

MEDICAL HISTORY CONSENT AND RELEASE FORM

Please circle YES or NO:

YES NO Diabetes

YES NO HIV

YES NO Heart Condition

YES NO Faintness or Dizzy Spells

YES NO Epilepsy

YES NO Hemophilia

YES NO Eczema/Psoriasis

YES NO Scarring/Keloiding

YES NO T.B.

YES NO Asthma

YES NO Herpes

YES NO Pregnant/Nursing

YES NO Hepatitis

YES NO Infections

YES NO Blood Thinners

YES NO Prophylactic Antibiotics

Do you have allergies? YES NO If yes, please list:_____________________________________________

Do you take medications? YES NO If yes, please list:__________________________________________

Are you currently under a doctor’s care for a continuing condition? YES NO

Are there any know medical problems that may affect you getting a piercing? YES NO

When is the last time you ate? _____________________

Please Read:



This is to certify that I am at least 18 years of age.



I am not under the influence of alcohol or drugs.



I understand there is a possibility of an allergic reaction.



I understand there is a possibility of an infection.



I understand the potential for damage to my oral health by my choice to receive an oral piercing.



I agree to follow all instructions given to me by Fine Line Tattoo and its employees concerning the aftercare of my piercing.



I understand that there is a chance I might feel lightheaded, dizzy and/or faint due to my decision to receive a piercing.

*If you feel this way during or after the procedure, please let us know immediately.



I understand there are NO REFUNDS.



I’ve been given a chance to ask questions and they’ve been answered to my satisfaction.

I hereby release Fine Line Tattoo & Body Piercing, LLC and its employees of all responsibility and liability for said piercing.

Signature _______________________________________Print Name____________________________________

Address ________________________________City, State_____________________ Phone # ________________

D.L. #_______________________Today’s Date ________________ D.O.B. ________________ Age __________

Parent/legal guardian to fill out this section entirely:

If under 18, child AND parent/guardian signatures are to be done in the presence of a notary. Parent/guardian

must be present throughout the procedure and proper I.D. must be shown prior to service.

_____________

I, (print name)_______________________________________ give permission for my child to receive a piercing.

Parent/Guardian Signature ______________________________________ D.L. # _______________________

Address_____________________________________________ City, State ____________________________

Notary’s Statement:

Sworn and Scribed before me on this _______ Day of ______________ 20____.

Notary signature: ______________________________________________ Seal:

-------------------------------------------DO NOT WRITE BELOW THIS LINE-------------------------------------------

New Piercing ____

Stretching ____

Jewelry Insertion/Removal Only ____

Cleaning ____

Placement __________________________________ Jewelry Used ____________________________________

Piercer _____________________________________ Care information given: Verbally ____ Written ____

Remarks: ___________________________________________________________________________________

___________________________________________________________________________________________

BODY PIERCING

Body Piercing Medical History Consent And Release Form

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