Waiver

Type of Service *

Are you OVER 18 Years Old *YesNo

Legal Guardian Consent Required - Please complete the waiver on behalf of your child

Suffers from any heart conditions (e.g prosthetic heart valve/ heart valve disease/ angina/ blood pressure problems)?NoYes

Conditions

Suffers from haemophilia/other clotting disorders?NoYes

Suffers from epilepsy? If Yes, how controlled?NoYes

Epilepsy

Suffers from any ‘lumpy’ raised scars (keloid scars)?NoYes

Suffers from any problems with skin healing in the past, e.g psoriasis, eczema?NoYes

Suffers from diabetes or lupus?NoYes

Suffers from any known allergic responses e.g. plasters/creams/metals/iodine/shellfish/latex/food - stuffs/other? Indicate which:NoYes

Allergies

Is the client pregnant?NoYes

Prone to ‘fainting attacks’? If Yes, state reason:NoYes

Fainting

Any known/previous reactions to dye pigments?NoYes

Any previous piercing at proposed site?NoYes

Have you consumed alcohol/ drugs in the last 24 hours?NoYes

Had any surgery in the area of the proposed Tattoo/PiercingNoYes

Surgey

Name *

Contact Number

DoB *

Email Address *

Street Address

City

Post Code

Guardian Name *

Guardians Contact Number *

Submit ID (Guardians ID if under 14)

I (State Your Name) *

declare that I give that I give my full consent to tattooing being carried out by the aforementioned practitioner. I confirm that potential complications, (e.g. infection, swelling (for both tattooing and piercing), gum/tooth damage, 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 site 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.’

declare that I give that my body piercing/ piercings has been carried out professionally with sterile equipment in hygienic premises. I have been told how to care for my piercing, given aftercare instructions and agree to follow hygienic aftercare to maintain good healing.

address

working hours