General Inquiry Form

Please answer all questions and acknowledge all text in this form. All of the information is important. Piercer Von Peri agrees to review all answers before tattooing.

Email *

Your First and Last name *

Birth Date *

Please confirm the date and time of your appointment *

Cell Phone number *

Preferred pronouns

Do you permit your piercer to post photos of your piercing on their online portfolio / instagram? If so please provide your @handle. If not ok to post/tag or take pictures of your piercing please note here and also verbally remind your piercer. *

Health and Safety Section

The following section is pertinent to client health and safety, please read carefully before responding.

Have you eaten within the last 4 hours? *

Have you had any alcoholic beverages in the last 8 hours? *

Do you have any history of epilepsy, seizures, fainting or narcolepsy? (if yes, please specify) *

Do you have any history of hemophilia or excessive bleeding? *

Yes

Have you taken any medications that thin the blood and/or interfere with blood clotting (including aspirin) within the last 24 hours? (if so, please specify) *

Do you have any history of allergies or adverse reactions to latex, disinfectants, metals or other sensitivities related to piercing procedures? (if so, please specify) *

Please provide an emergency contact name and number below *

If you are a minor please provide the first and last name of the guardian accompanying you. Both guardian and client will be asked to provide photo ID unless we have it on file (please talk to desk assistant about it)

Please check every applicable box regarding your current health/exposure status. If you cannot check any of the below, please discuss situation with our manager before proceeding. *

I have not been sick or shown any Covid and flu related symptoms in the last 5 days

I have not been exposed to anyone with Covid symptoms or anyone that could possibly or tested positive for Covid in the last 10 days

I acknowledge that I have asked any and all questions that may pertain to my piercing changeout or taper and have been answered to my satisfaction. I have also notified the piercer of any relevant allergies, communicable diseases, health conditions, or medications taken. I also understand that we follow all appropriate sterilization and disposal procedures. *

Please re-enter your full name here as an electronic signature, confirming that you've read and completed this form: By my electronic signature below, I certify that I am healthy & 18 years of age or older, or am accompanied by a parent/guardian.. I understand that by providing false information or producing false documents, I am liable for prosecution. This document is specific to the piercer AZIZA NARVAEZ CORREA, please accept this as her electronic signature and acknowledgement of your answers. Please inform us if you would like a printed copy of this document. *

Changeout Form / Piercings

Changeout Form/ Piercings

Health and Safety Section

Thank you for taking the time to fill out our electronic intake form!

Changeout Form/ Piercings