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Piercing Consent Form
Have you EATEN before this procedure?

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

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

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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