First Name *

Last Name *

Phone *

Address *

Email

State *

Postal code *

Where did you find us?

'Tap' on month and year to change it:

Date of birth *

Are you over 16? *

Yes

No

Please provide a photo of your ID

PDF, JPEG, JPG or PNG

(If Female) are you pregnant?

Yes

No

Do you suffer a heart condition?

Yes

No

(ONLY for nipple/genital piercings or procedures such as branding / Implants) Are you over 18 years old

Yes

No

N/A

Do you have any Medical Condition that may affect you during this procedure?

Yes

No

If applicable Please describe your condition:

*

I declare that I am over the age of 16 years (unless otherwise stated and written permission given)and all the information provided by me is true and correct. I declare that the staff at Body Pleasure Piercing ahve informed me of the risks concerning any desired procedure and they have explained the healthing process, including aftercare to me. Body Pleasure Piercing have provided me with healing sintructions. I hereby take full responsibility for my piercing/implant or other adornment. I understand that body pleasure piercing cannot be held liable for any problems I may have upon leaving the premises. I have read and I do fully understand this release form.

Please Provide your signature as approval for this procedure

Clear

Guardian Permission

Guardian Full name

Guardian Photo ID

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

I am confirming that I am a legally appointed guardian for, and can sign off for the above mentioned

Yes

Guardian Signature

Clear

Please hand back to staff

A few quick details to get you started!