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Phone Number *

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Child's Age

Child's Name

I am the parent or legal guardian

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Have you eaten in the last FOUR hours? *

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Are you prone to fainting? *

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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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Health and Consent Form

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