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Piercing Consent Form
Have you EATEN before this procedure? Required

Have you experienced, or are currently experiencing, any of the following?

Skin disorders such as PSORIASIS, ECZEMA, ACNE, IMPETIGO, DERMATITIS Required
Heart conditions such as ANGINA, HEART DISEASE, CONGENITAL HEART PROBLEMS Required
Immune system disorders such as HEPATITIS, HIV OR AIDS Required
Blood disorder such as HAEMOPHILIA, HIGH BLOOD PRESSURE, DIABETES
SEIZURES, EPILEPSY, FAINTING OR DIZZY SPELLS Required
ALLERGIES to NICKEL or ALCOHOL Required
BULIMIA Required
PSYCHIATRIC DISORDERS Required
CURRENTLY PREGNANT OR BREASTFEEDING Required
PREVIOUS PIERCING in AREA to be PIERCED Required
An INFECTION in AREA to be Pierced, or INFECTION within the body Required
Currently taking BLOOD THINNING MEDICATION such as ASPIRIN or WARFARIN Required
Have you consumed any ALCOHOL or DRUGS within the last 24 hours? Required

Please tick the box to confirm you have read and understood each statement.

With a disposable needle and to insert a TITANIUM piece of JEWELRY in the PIERCING.

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