Piercing Request Form
Name
First Name
Last Name
Age
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Select Piercing
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Earlobe
Please enter a short description.
$30.00
$
30.00
Quantity
0
1
2
3
4
5
Â
Â
Eyebrow
$60.00
$
60.00
Quantity
0
1
2
Â
Â
Conch
$60.00
$
60.00
Quantity
0
1
2
3
4
5
Â
Â
Notes & questions you want to add
Appointment
I agree with the following statements:
I will wear a mask when entering the building. I will provide photo ID.
I understand failure to arrive on time, failure to bring a valid ID or failure to reschedule within 24 hours will result in forfeiture of deposit.
I will show proof of COVID vaccination with physical card and my vaccination will be at least 15 days prior to my appointment.
Signature
Submit
Should be Empty: