Parental Consent Form - Piercing

I, _______________________ (print parent's name), certify that I am the parent or legal guardian of________________________ (print child's name). I am giving my consent for the above named child to be Pierced by Wild Side Tattoo. I certify that the child is not pregnant, not taking any prescription drug which might adversely affect the procedure (such as anti-coagulants), and does not have any medical conditions which might adversely affect the procedure.

I understand that my child will be given care instructions, and that it is necessary that he/she follow all the instructions to insure the proper healing of the piercing. I understand that deviating from these instructions can result in improper healing, infection, and possible scarring.

In addition, I release Wild Side Tattoo and any related parties from any liability which may arise as a result of my child being Pierced.

The following information is required by the Department of Health.

Print Parents Name: ___________________________________ Date: _____________

Address: _____________________________________________ Ph #: _____________

Child's Date of Birth: _______________________________ Race & Sex: __________

Type of Piercing: ________________________________________________________

Physician's Name, Address, & Phone Number: ________________________________________________________________________

Emergency Contact's Name, Address, & Phone Number: ________________________________________________________________________

Please List Any Allergies (particularly to medication): ________________________________________________________________________

Do you have any history of Bleeding Disorders? ______________________________

Parent's Signature: ______________________________________________________
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