A few quick details to get you started!
First Name
*
Last Name
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Phone
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Address
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Email
State
*
Postal code
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Where did you find us?
Let us know how you came across Body Pleasure Piercing
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Date of birth
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Are you over 16?
*
Yes
No
Please provide a photo of your ID
(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
Guardian Photo ID
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
All done!
