PIERCING CLIENT FORM

In consideration of receiving a piercing from Thirdeye Beauty and Wellness LLC including its artists, associates, apprentices, agents, or any employees (hereinafter referred to as the “Tattoo Studio” I agree to the following:

First name

Last name

Address

Phone

Birthday

Month

Day

Year

Age

Sex

Female

Male

**If you are under the age of 18 you will need a signed and notarized form provided by Thirdeye Studio. We donot provide notarizing service. Parent or guardian must be present during piercing for anyone under 16.**

Emergency Contact

Emergency Contact Phone

Doctor or Physician Office

I will provide my own below

Jupiter Medical Center , 1210 Old Dixie Hwy, Jupiter FL 33458, (561)-263-2234

Doctor or Physician Office

Are you known to pass out, have low blood sugar or low iron levels ?

Do you suffer from any bleeding disorders?

All questions about the body piercing procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the body piercing I am about to receive. I have been informed about what I can expect following the piercing.

I understand that body piercing can result in nerve damage, and that if I choose to remove my jewelry, permanent holes or scars may be left.

I am the person on the legal ID presented as proof that I am at least 18 years of age, or the body piercing will be performed in the presence of my parent or legal guardian with notarized form.

I am not under the influence of alcohol or drugs and that I am voluntarily submitting to body piercing without duress or coercion.

I understand there is a possibility of an allergic reaction to the jewelry inserted into the fresh body piercing. I understand there is a possibility of getting an infection, and I have been advised of the signs and symptoms of infection that indicate a need to seek medical attention. agree to follow all instructions concerning the care of my body piercing.

Please list what piercing/s you are receiving.

Please list any allergies if you have any

Piercing Artist

Nikki Arensman

Brooke Marquez

Your Signature

Signature field is empty.

Date and time

Month

Day

Year

Time

HoursMinutes

Upload a photo of your ID

--------------ARTIST USE BELOW THIS ------------------

ARTIST SIGNATURE

NIKKI ARENSMAN

BROOKE MARQUEZ

Piercing location / Jewelry used / Gauge and Metal Used / Any complications