Professional Tattoo & Piercing Studio Liverpool

Your Information

Name *

First

Last

Email *

Email

Confirm Email

Contact Telephone Number *

Date of Birth *

Age *

Type of ID

Photo of ID

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Parent/Guardian Signature

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Which country do you reside in? *

Piercing and Appointment Information

I understand that the potential risks of the procedure are: • Scarring, Blood Poisoning(Septicaemia) • Jewellery Embedding/Migration • Localised Infection, Allergic Reactions to Jewellery • Localised Swelling & Trauma • Tongue Piercing May lead to swelling, choking & restriction of the airway. Tooth/Gum Damage (if applicable) *

Yes I understand and accept the risks.

I understand that healing times vary from person to person however general healing times can be as follows; earlobe, eyebrow, septum, lip, tongue & navel 4+ months; cartilage such as helix, Tragus, nose etc 6+ months; nipple 8-12+ months. *

Yes I understand and accept that times may vary.

Piercer Name *

Type and Location of Piercing *

Date & Time of Appointment *

Date

Time

I confirm that I do not currently suffer from or have a history of: *

I confirm that the following is correct and that I do not currently suffer from or have a history of any of the medical conditions listed.

Impetigo, Cellulitis, Eczema, Psoriasis, Heart disease/disorders, Haemophilia, Low or High blood pressure Epilepsy, Diabetes HIV, Hepatitis B/C
Conditions which compromise the immune system,
Conditions that may cause haemorrhaging e.g leukaemia.
Conditions which may cause excessive bleeding Allergies to metals(including Nickel), Latex, antiseptics, adhesive dressings or topical dressings and medicines.
I am not under a course of medication.
I am not pregnant or breast feeding.
I am not under the influence of Alcohol, and or drugs. I have not taken Aspirin or other medicines that thin the blood.
I am over 18 years of age or that my Parent/Guardian has signed this from.
I agree to follow the procedures outlined in the written aftercare and understand that neglect to follow these procedures or poor hygiene could lead to improper healing of the tattoo and infection.
I have checked and verified the spelling of any lettering included within my tattoo(if applicable).
I do not suffer from any other condition through which my health may be compromised when receiving a Piercing.

Your Consent to the Procedure

I give my consent to the procedure *

I confirm that I give my consent to the procedure and have read and agree with the terms and conditions below.

I declare that I give my full consent to the Piercing procedure being carried out by the practitioner named above. I confirm that the potential complications, e.g infection and swelling for the procedure undertaken, and aftercare instructions have been explained to me. I understand that I must follow the instructions given on the written aftercare sheet. I confirm that the information provided by me on this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure(e.g 16 for non intimate piercings and 18 for intimate piercings, if under 16 for piercings parent/guardian must countersign this form) and that I am not under the influence of alcohol or drugs. I confirm that I have requested the procedure of my own free will. I hereby release Design 4 Life Tattoo Ltd and the Piercer named above from all manner of liabilities, claims, actions and demands in law or in equity. I understand the Piercer named operates on a self employed basis within Design 4 Life and this agreement is in force between you the client and the Piercer named. I understand Design 4 Life will retain this form for Internal Record keeping and compliance purposes and that information on this form will be stored on computer.

Piercing Consent

Your Information

Piercing and Appointment Information

Your Consent to the Procedure