Body Piercing And Tattoo Release Form


Body Piercing and Tattoo Release Form
Date of Birth
If under 18, Parent Name
Parent Signature
Driver’s License (or other ID)
 Tattoo  New Piercing  Stretching
 Cleaning  Jewelry
Purpose of Visit
Body Part (for piercings):
Medical History (Check All That Currently Apply to You)
 Hemophilia
 Hepatitis
 Diabetes
 Epilepsy
 Tuberculosis
 Herpes
 Scarring
 Keloiding
 Asthma
 Heart Conditions
 Anemia
 Dizziness
 Fainting Spells
 Eczema
 Pregnancy/Nursing
Current Injuries/Wounds:
Current Infections:
Current Medications:
Last Time You Ate:
Last Time You Drank Alcohol:
Post-Procedure Care:
I, the undersigned, do hereby swear and attest that the aforementioned information is factual and true, and that the dangers inherent in
receiving a piercing or tattoo have been explained to me in a written/verbal statement. I understand that infection and/or allergic
reactions are possible, and that it is my responsibility to follow the care instructions provided above. I verify and attest that I am at
least 18 years old, that I am not under the influence of drugs or alcohol, and that it is up to me to ask questions and to speak up if I feel
dizzy or faint during the procedure.
Client Signature
I, the legal guardian of the client, do hereby grant permission for my child to receive the procedure listed above.
Parent Signature


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