top of page

Piercing Consent Form

Client's Information

Date of Birth
Day
Month
Year

Medical Information

Are you on any medication?
Yes
No
Have you had any aesthetics or surgery, within 6 months?
Yes
No
Please mark any of the following conditions that you may currently have:

Consent & Agreement

I declare that I give my full consent to the body piercing being carried out today at Pro Skin Clinic. I confirm that potential complications, (eg infection, swelling, gum/tooth damage, nerve damage, rejection, scarring, keloids, irritation bumps, allergies, bleeding, 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 area 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 (as explained to me by the practitioner) and that I am not currently under the influence of alcohol or drugs.

Please tick this box to indicate you have read the above information.
Date
Day
Month
Year

For Piercer Use Only

Date
Day
Month
Year
bottom of page