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PLEASE DO NOT FILL OUT THIS WAIVER UNTIL THE DAY OF YOUR SCHEDULED APPOINTMENT

Clients Date of Birth
Month
Day
Year

Please answer the following questions about allergies and medical conditions.

Are you diabetic?
No
Yes
Do you have a history of hemophilia?
No
Yes
Do you have a history of skin diseases?
No
Yes
Do you currently have any skin lesions?
No
Yes
Do you have a sensitivity to soaps or disinfectants?
No
Yes
Do you have a latex allergy?
No
Yes
Do you have sensitivities to adhesives?
No
Yes
Do you have a history of seizures, fainting, narcolepsy?
No
Yes
Do you take any medications that thin the blood or interfere with blood clotting?
No
Yes
Are you pregnant?
No
Yes
Are there any other conditions or allergies we should be aware of?
No
Yes
I certify by checking the boxes below that I am 18 years of age or older. OR Under 18 years of age receiving strictly a piercing service accompanied by a legal parent or guardian.
Electronic Signature Consent
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving the right. After consent you may, upon written request to us, obtain a paper copy of the electronic record. No fee will be charged for such a copy and no special hardware or softwa
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