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Hamptons, Ink
Piercing Consent Form

Client Information

Client First Name

Client Last Name

Age

Date of Birth

If Client is a Minor:

Parent/Legal Guardien First Name

Parent/Legal Guardien Last Name

Phone Number

Email

Street Address

City

State / Province

Postal / Zip Code

Pre-Procedure Questionnaire

Are you under the influence of alcohol and/or any other drugs? *

No

Yes

FEMALE ONLY: Are you pregnant or nursing?

No

Yes

Do you have a communicable disease? *

No

Yes

Please tell about your medical history (e.g. Hemophilia, Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease (such as hepatitis, HIV, AIDS, etc.))

Do you have any skin conditions? *

No

Yes

If yes, please explain skin condition and severity (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)

Acknowledgment and Waiver

I consent to the application of the piercing from Hamptons Ink & its representatives, and to any action or conduct reasonably necessary to perform the piercing procedure.

Hamptons Ink and its representatives have fully explained to me the nature of the procedure(s) and have informed me of the potential complications and risks, including, but not limited to: bleeding, pain, swelling, infection, prolonged healing, scarring, nerve damage, fainting, and death.

I am aware the Body Art Procedures are invasive and may involve possible health risks, especially for people with certain underlying medical conditions. I am also aware that I should consult with a physician prior to receiving any Body Art Procedure.

If I experience an adverse effect during the healing period related to the Body Art Procedure I received, I have been advised to seek medical care as soon as possible & advise the Body Artist and/or Body Art Establishment where I received the procedure.

I have been provided with Aftercare Instructions for my particular Body Art procedure. I have also had the opportunity to have any questions about the procedure answered.

I understand that this procedure is a change to my skin, body, and. appearance.

I allow my piercing to be photographed and be used for Hamptons Ink portfolio in print or on the web.

I acknowledge that it is not reasonably possible for the representatives and employees of Hamptons Ink to determine whether I might have an allergic reaction to the jewelry or process used in my piercing, and I agree to accept the risk. that such a reaction is possible.

I acknowledge that infection is always possible as the result of obtaining a piercing, particularly in the event that I do not take proper care of the piercing, and I agree to follow all instructions concerning the healing process.

To my knowledge, I do not have any physical, mental, or medical impairment or disability that might affect my well-being as a direct result of my decision to have any piercing-related work done at this time.

I confirm that I have truthfully represented to Hamptons Ink & its representatives that I am over the age of 18 years, and that all information I provided in this document is accurate and true.

I agree to release and forever discharge and hold harmless Hamptons Ink and its representatives from any and all claims, damages, and legal actions arising from or connected in any way with my tattoo or the procedures and conduct used to apply my tattoo.

Today's Date

Client Signature (or Parent/Legal Guardian Signature)

Thanks for submitting!

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Hamptons, Ink Piercing Consent Form

Hamptons, Ink
Piercing Consent Form