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

Email

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 do not provide notarizing service. Parent or guardian must be present during piercing for anyone under 16.**

Emergency Contact

Emergency Contact Phone

Emergency Contact Address

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 Name

Doctor or Physician Office Address

Doctor or Physician Office Phone Number

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

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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