Piercing Client Intake and Consent
Form must be completed prior to piercing procedure
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Email *
What is the date of your scheduled service
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Location: 450 W 910 S Heber City, Utah 84032.       
                   

First and Last Name
*also name of client if different from you
*
Client Date of Birth  *
Todays Date. (MO/DAY/YR) *
Client's Age *
Street Address, City State and Zip
*
Phone Number *
Emergency Contact - 
1. Name 
2. Phone number
3. Relation
*
Health History & Consent 
#1 - Pregnant or Nursing
*

l am not pregnant or nursing. If I have any condition that might affect the healing of this

piercing, I will i inform my piercer

Required
#2 - Medical Conditions *

I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing

Required
#3 - Allergies *

I have advised the Piercer of any allergies to metals, latex gloves, soaps and medications, etc.

Required
#4 - Piercing Reaction *

I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.

Required
#5 - Conditions *

I do not have a history of diabetes, hemophilia, epilepsy, seizures, fainting, or Narcolepsy; use of medications such as anticoagulants, which thin the blood/and or interfere with blood clotting. If I have any condition I will inform my piercer

Required
#6 - Legal Consent *

I have trustfully represented to the piercer I am over the age of 18 years or the legal guardian of the client. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing done at this time

Required
#7 - Consent to Pierce *

l acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition. I acknowledge infection is always possible as a result of obtaining a piercing. I will receive aftercare instructions and I agree to follow all of them while my piercing is healing.

Required
#8 - Sterilization *

I understand I will be pierced using only sterile earrings and with appropriate instruments and sterilization.

Required
#9 - Waiver of Claims and Legal Responsibility *

I agree to release and forever discharge and hold harmless the piercer and all employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing.

Required
#10 - Healing Release of Liability *

I understand some types of piercings takes longer to heal. I accept the risk and agree to contact my piercer and a doctor if I experience signs of infection such as fever, excessive redness and swelling. My responsibility to follow aftercare instructions will greatly improve my ability to heal. I release any and all liability of any future medical attention, fees and follow up care I may receive as result of any possible infection or adverse reactions that having a piercing may incur. 

Required
#11 Photo/Video Consent *

I give consent to have photos or videos taken at my piercing that may be used in social media

Required
#12 Aftercare *

I accept all aftercare instructions in writing below as well as that I will receive verbally from my piercer.

Required
#13 - Jewelry Consent *

I acknowledge and agree to the use of the specific type of earring recommended by Glam Studio Pros for my piercing, understanding that this recommendation is based on their professional training and current research to ensure the best outcome for my piercing experience and healing

Required
Electronic Signature *
"By typing your name below, you acknowledge that all the information you have provided is accurate and truthful to the best of your knowledge, and you consent to the terms, aftercare and waivers outlined in this form."

I acknowledge that I have read and understood the terms of this teeth whitening consent form and agree to its conditions.

***Type your name below if you are the guardian or client

SMS Consent (Required)

*
I agree to receive transactional SMS messages from Glam Studio Pros related to my appointment, aftercare instructions, healing reminders, and service-related follow-ups.
Message frequency varies. Message & data rates may apply.
Reply STOP to unsubscribe, HELP for help.
Privacy Policy: https://www.glamstudiopros.com/privacy-policy
Terms & Conditions: https://www.glamstudiopros.com/terms
Required
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