Minor Piercing Consent Form

Minor's Full Name

First NameLast Name

Parent/Guardian's Full Name

First NameLast Name

Relationship to Minor

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Minor's Date of Birth

Date

Type of Piercing

Location of Piercing

LeftRightBoth

Has the minor received all necessary vaccinations?

YesNo

Does the minor have any allergies? If yes, please specify.

Has the minor had any recent surgeries or medical procedures? If yes, please specify.