Client Intake Form

Full Name *

Sex *

Date of birth

Phone *

Email *

Date Today

Service Needed

Tattoo Artist

Piercer/Practitioner

Type of Piercing

Jewelry Description

Complications

Please state any present medical conditions or past major health events.

Terms of Service

Risks *

That I have been fully informed of the risks, associated with getting a piercing. I understand that these risks, known and unknown, can lead to injury, including but not limited to infection, scarring and keloiding and allergic reactions. Having been informed of the potential risks associated with getting a piercing, I still wish to proceed with the piercing and I freely accept all risks that may arise from piercing.

Release *

I WAIVE AND RELEASE to the fullest extent permitted by law each of the Artist and the Piercing Studio from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise, whether caused by the negligence or fault of either the Artist or the Piercing Studio, or otherwise.

Aftercare *

I affirm that I have given me instructions on the care of my piercing while it.s healing, and I understand them and will follow them. I acknowledge that it is possible that the piercing can become infected, particularly if I do not follow the instructions.

Duress *

I affirm that I am not under the influence of alcohol or drugs, and I am voluntarily getting a piercing without duress.

Medical Condition *

I affirm that I do not have diabetes, epilepsy, hemophilia, nor do I have a heart condition or take blood thinning medication. I do not have any other medical or skin condition that may interfere with the procedure or healing of the piercing. I am not the recipient of an organ or bone marrow transplant or, if I am, I have taken the prescribed preventive regimen of anti-biotics that is required by my doctor in advance of any invasive procedure such as piercing. I am not pregnant or nursing.

Photography *

I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form.

Customer Information

Have you eaten in the past 2hrs? It's a good idea to before hand to increase your blood sugar levels. *

Do you have any bloodbourne pathogens, transmittable diseases or recent illnesses? (It' okay if you do, we just want to know for our and other's safety). *

Do You have any allergies? *

Please list down your allergies. *

Are you Pregnant? *

Customer Signature

Clear

Photo of ID *

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.