Personal Details
Piercing Details
Please answer all questions as accurately as possible. This information allows us to carry out your piercing safely and identify anything that may affect healing or the suitability of the procedure. If you are unsure about any question, please ask your piercer before signing. All information is confidential.
General Health
Do you have any heart conditions?
If yes, please describe your condition and any treatment you are receiving
Do you have any blood clotting or bleeding disorders?
e.g. haemophilia, von Willebrand disease, or blood thinners
Do you have diabetes, lupus, or any autoimmune condition?
These can affect healing time and suitability
Do you have any skin conditions that affect healing?
e.g. eczema, psoriasis, keloid scarring, history of poor wound healing
Have you ever had an epileptic seizure or fainting episode?
Please describe frequency and any known triggers
Allergies & Medications
Do you have any known allergies?
Include allergies to metals, latex, plasters, iodine or any other substances
Are you taking any prescribed medication?
Please list all medications including anticoagulants, steroids, immunosuppressants, or antibiotics
Are you taking any non-prescribed medication/supplements?
Include vitamins, herbal remedies, aspirin, ibuprofen, or recreational substances
Additional Information
Is there anything else about your health/medical history we should know?
Please include anything not covered above that may be relevant
| Question |
Yes |
No |
| Do you have a known blood-borne virus? (e.g. Hep B, Hep C, HIV) |
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| Have you had any previous adverse reactions to a piercing? |
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| Are you currently receiving medical treatment of any kind? |
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| Are you currently pregnant or breastfeeding? |
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| Have you consumed alcohol or taken any substances in the last 24 hours? |
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| Have you eaten within the last 2 hours? (Recommended before piercing) |
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Risks & Procedure Information
Body piercing carries inherent risks which vary by placement. These include but are not limited to: infection, localised swelling and bruising, bleeding, allergic reaction to jewellery, scarring or keloid formation, jewellery migration or rejection, and nerve sensitivity. For oral piercings there is a specific additional risk of tooth and gum damage if jewellery is not downsized promptly. All piercings are performed using single-use sterile needles. Jewellery used is implant-grade titanium. Healing times vary significantly - full written aftercare instructions will be provided.
Client Declaration
By signing below I confirm that:
I give my full and informed consent to the body piercing procedure described on page 1 of this form, to be carried out by the named practitioner at Savage Piercings. I confirm that the potential risks and complications of the procedure have been explained to me verbally, and that written aftercare instructions have been provided. I accept that if I move during the procedure this may cause misalignment, and that the piercing may not be able to go ahead until the healing process is completed.
I confirm that all information provided on this form is truthful and complete to the best of my knowledge. I understand that withholding relevant medical information may affect the safety of the procedure and that Savage Piercings cannot be held liable for any adverse outcomes arising from undisclosed conditions. I confirm I am not currently under the influence of alcohol or any substances. I understand that a piercing may result in a permanent change to my appearance, and I accept this knowingly and willingly.
I understand and accept that correct healing of my piercing is entirely my own responsibility. I have been provided with full written aftercare instructions and I agree to follow them without deviation for the full duration of the healing period. I acknowledge that I was given the opportunity to ask questions of my practitioner before, during, and after the procedure, and that any questions I had were answered to my satisfaction. I accept that Savage Piercings cannot be held liable for any adverse healing outcomes, complications, or injuries that arise as a direct or indirect result of failure to follow the provided aftercare instructions, failure to seek timely medical advice when needed, or failure to raise any concerns or questions with the practitioner at the time of the procedure. Responsibility for aftercare and healing lies solely with the client from the point of leaving the studio.
I understand that the aftercare instructions provided by Savage Piercings are professional guidance and do not constitute medical advice. In the event of any concern, unusual symptoms, or signs of infection, I accept that I should seek qualified medical advice promptly and that the advice of a medical professional always supersedes any guidance provided by the studio. Savage Piercings cannot be held responsible for any decision to delay or avoid seeking medical attention.
Parental / Guardian Consent - Complete if client is under 16
I am the parent or legal guardian of the client named on this form. I consent to the body piercing procedure described above being carried out on the minor named. I confirm I have read this form in full, that all information provided is accurate to the best of my knowledge, and that the procedure and aftercare requirements have been explained to me. I understand that Savage Piercings performs ear lobe piercings on clients aged 7 and over, and a limited range of other piercings on clients aged 16 and over, with full parental consent and the parent or guardian present throughout.
Parent / Guardian Signature
Practitioner Sign-Off
Staff Use - Confidential
Any concerns, observations, or follow-up required