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PIERCING CONSENT FORM

First name*

Last name*

Birthday*

Month

Day

Year

Government ID (Driver’s License/Passport*

Phone*

Email*

Address*

Is the client over 18 years of age?*

Yes

If No, please have Parent/Legan Guardian present with proper ID ready and they must fill out the fields below:

Full Name

Relationship

Phone #

Guardian Government ID (Drivers Licence/Passport

Birth Certificate of Minor

Body Modification Location:

I am the legal guardian of the client and I give full consent for the body modification.

Guardian Signature:

Signature field is empty.

Please Check the following:

I am at least 18 years old or have a guardian present and have proper consent for this body modification.

I have eaten in the past 4 hours

I have not consumed alcohol in the past 24 hours

I am not currently taking any non-prescribed medications or illegal drugs

I understand that the body art technician is not responsible if my body reacts negatively to the body modification

I understand that the body art technician’s suggestions are not to be confused with medical advice

I will do my due diligence to read the aftercare instructions and I understand I am responsible for taking care of my body modification

I am aware and understand the instruments used in my body modification are sterilized

Please check if any of the following apply to you:*

Heart Disease

Prone to Fainting

Diabetes

Epilepsy

H.I.V./A.I.D.S.

Hepatitis

Keloid Scarring

Heavy Bleeding

Pregnancy

Cold Sores

Other

None

Other Medical Conditions:

By signing below I give permission to the Body Art Technician at The White Wasp Tattoo Studio, LLC. to perform a body modification procedure. I have answered all the questions truthfully, I am aware and take full responsibility for the body modification process, healing, and daily aftercare procedure.

I agree to the Terms & Conditions and I understand there are no Refunds for any reason whatsoever.

Client Signature*

Signature field is empty.

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509 S 820 W

Logan UT, 84321

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