Tooth Jewellery Consent Form

I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about the obtaining of a piercing and that all of my questions have been answered to my full satisfaction. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows.

"*" indicates required fields

Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Email*

Phone*

Address*

Street Address City Post Code

Do you have any allergies?*

Allergy Detail*

Please detail any allergies

Do you have, or have you recently been affected by the following:

Abscess/ulcer

Brittle Teeth

False Tooth/Veneers

Pregnant/Breastfeeding

Invisalign/Retainer

Halitosis

Oral Herpes

Recent Dental Surgery

Sensitive Teeth

Within the last 48 hours have you experienced any vomiting, diarrhoea or any form of virus or infection?*

Consent*

I confirm that I am of sound mind and agree to follow the aftercare provided. I understand that my tooth gem can last anywhere from one month to one year depending on how well I look after them and to achieve longevity I must follow the aftercare.

I understand that by going ahead with treatment all information provided is correct and I am going ahead at my own discretion.

I agree and consent to this treatment.

Signature*

Input your full name, as spelt above, to form a digital signature.

Date*

Please input today’s date to complete your digital signature.

DD slash MM slash YYYY

Please tick the box if you would like to receive information including marketing via:

Email

Phone/SMS

Privacy*

I agree to the privacy policy.

You must agree to all of the above statements in order to continue with your booking. If you do not agree, please speak to reception.

Contact The Studio

[email protected]
01525 217 121

Services

Tattoo
Piercing
Laser Removal

Tattoo
Piercing
Laser Removal

About

The Studio
The Team
Pricing

The Studio
The Team
Pricing

Forms

Tattoo Consent Form
Piercing Consent Form

Tattoo Consent Form
Piercing Consent Form

Privacy Policy
Terms & Conditions

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