1.___ I am not pregnant or nursing. I do not have epilepsy or hemophilia. I do not suffer from any heart conditions or take any medication that thins the blood. (Including drugs such as aspirin, ibuprofen, and acetaminophen)

2.___ If I suffer from hepatitis or other communicable disease, I have informed the Piercer of this fact and have been advised of any medications and procedures necessary to promote the satisfactory healing of my piercing. (Dr. note required if your condition can interfere with a safe healing or your under 18*).

3.___ I do not suffer from medical or skin conditions such as, but not limited to: keloid or hypertrophic scarring, psoriasis at the site of the piercing or any open wounds or lesions at the site of the piercing.

4.___ I have advised the Piercer of any allergies to metals, latex gloves, soaps, and medications. I acknowledge it is not reasonably possible for the Piercer to determine whether I might have an allergic reaction to the piercing or processes involved in the piercing and further acknowledge that such a reaction is possible.

5.___ I have trustfully represented to the Piercer that I am over the age of 18 years. I am not under the influence of drugs or alcohol. To my knowledge, I do not have any physical, mental, or medical impairment or disability which might affect my well being as a direct or indirect result of my decision to have a piercing done at this time.

6.___ I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to later restore the skin involved in this piercing to its pre-piercing condition.

7.___ I acknowledge infection is always possible as a result of obtaining a piercing, and I agree to follow all instructions concerning the care of my piercing while it is healing.

8.___ I understand I will be pierced using appropriate instruments and sterilization techniques.

9.___ I understand that if I choose to wear materials not designated by ASTM or ISO as implant quality, I do so at my own risk.

Therefore, I request the Piercer to [pierce/stretch/change/insert/remove/view] my ______________________

I understand this type of piercing usually takes 30 to 90 days or longer to heal. I agree to release and forever discharge and hold harmless the Piercer and all employees from any and all claims, damages or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing.

[*To insert, remove, stretch, or view: My piercing is ___________________[days/weeks/months/years] old.]

Please list all current health conditions:_______________________
Allergies:_______________

Have you recently been ill or under a high amount of stress, physically or emotionally? [Y / N]

Explain:________________________________________________

Have you eaten something substantial in the past two hours? [Y / N]
Are you prone to fainting? [Y / N]

How many alcoholic beverages have you had in the past 24 hours? When?_____________________________________

List all medications you are taking or prescribed to take:______________________________________

How much do you smoke?________________per [day/week] How much caffeine have you had today?________________

How did you choose us?

[Word of mouth / Friend (s) / Yellow Pages / Free Times / City Paper /  www.FactorFive.com / Surfin Internet /  Previous visit / etc. / ]