Consent Form

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Consent Form

Please fill in this form before your procedure.
  • Please remind us of this on your visit.
  • FOR CLIENTS INFORMATION:
    Known potential risks

    Scaring, blood poisoning, jewellery migration/embedding, localised infection - particularly nose and navel, allergic reactions to jewellery metals, localised swelling & trauma around the site, tongue piercing may lead to swelling, choking & restriction of the airway.

  • Important information:
    You have requested a treatment that involves breakage of the skin surface with a sterile needle, and this process may complicate some medical conditions. Please read the following information carefully, and if any of these conditions apply to you, you MUST declare them to the operator on the premises and discuss the matter with him or her.

    SKIN CONDITIONS: Eczema- This may make a person more prone to skin infections or irritation, psoriasis or other chronic skin conditions, excluding acne and disorders of pigmentation- same complications as eczema.
    CIRCULATORY DISORDERS: Heart disorders can render individuals more prone to serious heart complications from any blood infections. High blood pressure can cause light headedness and may be linked to other heart-circulation disorders. Haemophilia and other bleeding disorders may result in poor clotting and healing.
    PREGNANCY: Nursing mother’s treatment must not interfere with the feeding process; also, any risk of infection for them is also potential risk to their baby. The immune response may also be affected by pregnancy; any infection may affect the unborn child.
    OTHER MEDICAL CONDITIONS: Epilepsy medication may cause side effects and poor control of the condition may result in fitting during treatment.
    Diabetes long term sufferers may have circulation problems that can reduce healing properties of the skin; this can result in severe infection.
    Autoimmune disease or other conditions or treatments causing immune-deficiency (e.g. cancer treatments) - more prone to serious infection; HIV a risk factor for operator and medication side effects may affect healing and recovery from treatment.
    IF YOU ARE SUFFERING FROM ANY OTHER MEDICAL CONDITION NOT LISTED PLEASE INFORM THE OPERATOR.

    OTHER CONSIDERATIONS BEFORE YOU UNDERGO TREATMENT: Treatment cannot be undertaken if you are under the influence of drugs or alcohol.


    I CONFIRM THAT I HAVE READ THE ABOVE INFORMATION AND DISCUSSED IT WITH MY OPERATOR.

  • Individual consent:
    I declare that I give my full consent to the procedure being carried out by the aforementioned practitioner. I confirm that potential complications (e.g Infection, swelling, gum/tooth damage, jewellery migration/imbedding) for the procedure undertaken, and aftercare instructions have been explained to me. If applicable a written aftercare advice sheet containing more detailed information has been given to me and I agree that it is my responsibility to read this and follow the instructions on it, until the site has healed. I confirm that the above information provided by me for this consent form is correct to the best of my knowledge, that I am over the age of consent for this procedure (i.e over 16 years of age) and that I am not currently under the influence of alcohol or drugs.
  • PARENTAL CONSENT FOR U18 (applicable for piercing)

  • I consent that all of the intended procedure has been explained to me and that the information provided by me is correct to the best of my knowledge. I hereby consent to my child (named above) having the body piercing and I understand the risks as summarised above.