I confirm I am the person on the valid photo ID presented as proof that I am at least 18 years of age, or I am the parent/legal guardian completing this form on behalf of a minor under 18.*

I confirm I am not under the influence of alcohol or drugs, and I am voluntarily choosing to receive this piercing without duress or coercion.*

I understand that removing a piercing may leave permanent scarring.*

All of my questions about this piercing procedure have been answered to my satisfaction, and I understand I will receive written aftercare instructions.*

I understand the restrictions associated with this piercing procedure as explained by my piercer.*

I understand that any medical information I provide is subject to the federal Health Insurance Portability and Accountability Act (HIPAA).*

I am aware of the signs and symptoms of infection, including but not limited to redness, swelling, tenderness at the site, red streaking away from the site, elevated body temperature, or discharge.*

I understand there is a possibility of infection as a result of receiving a piercing.*

I will seek professional medical attention if any signs or symptoms of infection occur.*

I agree to follow all aftercare instructions for my piercing, and understand that failing to do so may lead to improper healing.*

I understand there is a chance I may feel lightheaded or dizzy during or after being pierced.*

I agree to immediately notify my piercer if I feel lightheaded, dizzy, and/or faint before, during, or after the procedure.*

This piercing is for a minor under 18 — I am the parent or legal guardian completing the two sections below on their behalf.