Full Name *

Email Address *

Phone Number *

Address Line 1

Address Line 2

Country

ZIP / Postal Code

Child's Age

Child's Name

I am the parent or legal guardian

Yes

Have you eaten in the last FOUR hours? *

Yes No

Are you prone to fainting? *

Yes No

Are you allergic to latex or antibiotics?

Yes
No

Do you have.a history of herpes at the proposed piercing site? *

Yes No

Have you consumed drugs or alcohol in the last EIGHT hours? *

Yes No

Are you pregnant or have you given birth in the last FOUR months? *

Yes No

Do you have a history of medication use or are you currently taking medication prescribed prior to a dental or medical procedure? *

Yes No

Are you prone to have bleeding and/or have a blood condition such as hemophilia? *

Yes No

Do you have Diabetes, Cardio Valve Disease (MVP Micro Valve Prolapse) risk factors for blood born pathogen exposure, or any other condition (including ANY recent surgeries) that may affect the procedure or healing your piercing? *

Yes No

How did you hear about us?

What do you like most about Nathan's Tattoos & Piercings?

Identification

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Supported format: JPG, JPEG, PNG, GIF, SVG.

Date time

Signature (Authorization for procedure and photography) *

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I agree to the terms and conditions

Health and Consent Form

NeilMed