Consent Form - Needlework Body Art

First name

Last name

Birthday

Day

Month

Year

If you are a parent of guardian for the above named person please detail your relationship and full name below:

Email (or parent/guardians email)

Multi-line address

Country/Region

Address

City

Zip / Postal code

Decleration of Health and Wellbeing

Please answer the following questions honestly to allow safety for staff and your own health and wellbeing.

Do you have any of the following conditions?

Blood Borne Infections

No

Yes

Skin Infections

No

Yes

Blood Disorders or Blood Thinning Medications

No

Yes

Cardiac Conditions

No

Yes

Fainting Episodes or Low Blood Pressure

No

Yes

Pregnant or Breastfeeding

No

Yes

Allergies (in particular metals or topical ointments such as Savlon, rubbing alcohol, iodine etc).

No

Yes

I am not going through treatment for cancer currently, and have not in the last 6 months.

Agree

Disagree

Do you take any medications?

No

Yes

I am not under the influence of elicit drugs or alcohol.

Agree

Disagree

Treatment Risks -

Body Piercing procedures all carry certain risks. These risks are carefully assessed by your practitioner and care is taken to avoid these situations from arising with appropriate hygiene protocols and training in the services provided.

Please read below and indicate your consent to this procedure by signing underneath. Ensure to ask any questions you may have prior to signing this waiver to ensure you are comfortable with the information provided to you.

Fainting, nausea, and vomiting can occur during or after the procedure.
There is a risk of infection, allergic reaction, bleeding, and scarring.
You will likely experience some discomfort or pain during and after the procedure.
Proper aftercare is crucial to minimise these risks.

Do you consent to photographs being taken for marketing purposes?

Yes

No

Piercing being provided:

Customer Signature (or guardian signature if under age 16)

Signature field is empty.

Piercers Signature

Signature field is empty.

Date and time

Day

Month

Year

Time

HoursMinutes