Piercing Form

Piercing Consent Form
Client Information
Full Name*

First (Legal)First (Preferred)Last Name
Date of Birth*
Date of Birth*

MonthDayYear
Date
Age
Pronouns
Name of Parent or Guardian [if client is under 16]

First NameLast Name
Phone Number*

Area Code (604/250/etc)Phone Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Pre-Procedure Questionnaire
Who is your piercer today?

Eann (he/him)Grantham (they/them)
Which Piercing are you getting today?*
lobes/helix/nostril/ect
Have you been pierced in the past year?*
If so, when?
When was the last time you ate? *
1 hr ago, 30 min ago, last night, etc
Do you have a history of fainting or near-fainting?*

yesnounsure
Are you under the influence of drugs or alcohol?*

YesNo
Are you Pregnant or Nursing?*

YesNo
Do you have a communicable disease?*

YesNo
Are you on Accutane or any other medications that may interfere with healing?*

YesNo
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, etc.)
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Cosmetic Alterations to the area of the piercing (rhinoplasty, top-surgery, fillers, etc.)
If yes, please identify what alterations.
Acknowledgment and Waiver
I understand that a piercing is a permanent change to my body.
I allow my piercing to be photographed and be used for portfolio purposes.
I allow my piercing to be photographed and/or recorded for social media advertisement purposes
I acknowledge that NEXT does not offer refunds.
I understand that I need to follow the aftercare regime for proper healing and that if I need clarification or experience complications, I will ask for help.
I understand that there are lifestyle decisions and extracurricular activities that are advised against during the healing period, which includes swimming (ocean/river/lake/pools). I will bring up any extracurricular activities with my piercer before receiving the piercing.
I understand that there is always a risk for infection and scarring, but that by following the aftercare regime and practicing basic hygiene I can minimize my risk.
I confirm that the information I provided in this document is accurate and true.
Signed Date*

MonthDayYear
Date
Client Signature*

Clear
COVID-19 Information and Screening
I understand the following:*

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by theWorld Health Organization. COVID-19 is extremely contagious and is believed to spreadmainly from person-to-person contact.I understand that COVID-19.NEXT BODY ARTS 2019 INC (“the Facility”) has put in place preventative measuresto reduce the spread of COVID-19; however, infection from COVID-19 can happen anywhereand no business can guarantee or completely prevent someone from becoming infected.Further, being in any business could increase your risk of contracting COVID-19.To prevent the spread of contagious viruses and to help protect others, I understandthat I will have to follow the facility’s guidelines. The facility’s guidelines can be changed atanytime as new information and technology become availableI confirm that I am not presenting any of the symptoms of COVID-19 including: dry cough, runny nose, sore throat, shortness of breath, loss of sense of taste or smell, fever.I confirm that I have not been in close contact with anyone with these symptoms oranyone who has been diagnosed with COVID-19 in the past 14 daysI understand that air travel significantly increases my risk of contracting and transmittingthe COVID-19 virus. I verify that I have not traveled outside of British Columbia in the past 14 days.
Should be Empty:

Piercing Consent Form

Client Information

Pre-Procedure Questionnaire

Acknowledgment and Waiver

COVID-19 Information and Screening