General Inquiry Form

Email *

Your First and Last name *

Birth Date mm/dd/yy *

Please confirm the date and time of your appointment *

Type of piercing(s) getting today *

Cell Phone number *

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

No

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

Do you have any history of allergies or adverse reactions to any foods, pigments, dyes, disinfectants, metals or other sensitivities related to piercing procedures? (if so, please list below). Please note here and mention verbally to your artist if you have specific allergies/have had reactions to the following: LATEX, ADHESIVE, COCONUT OIL, LAVENDER, ALOE *

Are you pregnant or Breast Feeding? *

Yes

No

Maybe

Not Applicable

Do you have ANY CONDITIONS which may affect BLOOD CIRCULATION, ABILITY TO HEAL, OR FIGHT INFECTION? (If yes, 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 from a previous piercing (please talk to the desk assistant about it)

I acknowledge by signing this agreement that I have been given the full opportunity to ask any and all questions which I might have about obtaining a body piercing, micro dermal (single point piercing), or tooth gems and that all of my questions have been answered to my full satisfaction. I also understand we use all appropriate sterilization and disposal procedures. I specifically acknowledge I have been advised of the facts and matters set forth below and I agree as follows. *

Current Mask Policy. Per the latest executive order (79) and our regulatory board (VA DPOR, DOLI), our type of business is now able to make a choice whether or not to require mask wearing in our establishment for fully vaccinated individuals. We are choosing to allow these individuals the choice to remove their mask under certain circumstances. We are still requiring masks for everyone upon entry and in common areas (lobby, restroom, on breaks, etc). If you are fully vaccinated and would like to request to take off your mask during your service after you have been settled into your artist’s area, please certify to the following: *** Our business is allowed by law to require any individual to wear a mask upon entry, refuse service for not wearing a mask, and to require proof of vaccination in order to remove their mask during service. Please see executive order 79 and https://www.dpor.virginia.gov/COVID-19/ for reference. Our current mask guidelines are also contingent on our comfortability with local threat levels and new case numbers as provided by the CDC, which are currently on “green” or low threat level, but we will be monitoring continually***

*

I have not been sick or shown any Covid related symptoms in the last 10 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 have not traveled out of the country in the last 10 days

I will show my vaccination card to the desk assistant that shows I am fully vaccinated. We will not make a copy

I will notify my artist and check in with them before removing my mask, and will keep it handy in case they request to put it back on for any reason, go on break, use restroom, etc

I would not like to request to remove my mask

General Piercing Release Form Information

I acknowledge that obtaining this piercing is my choice alone and will result in a permanent change to my appearance, and that no representation has been made to me as to the ability to restore the skin involved in this piercing to is pre-piercing condition.
I acknowledge infection is always possible as a result of obtaining a piercing. I have received aftercare instructions and agree to follow all of them while my piercing is healing.
I understand that a microdermal (single point piercing) consists of a pierced point of entry but not a point of exit. Specially designed jewelry is inserted into the pierced area and sits below the skin where it becomes anchored.
I understand I will be pierced using appropriate instruments and sterilization.
I understand that unless I specify otherwise, Figure 8 Ink Studios reserves all rights to use any photos of my piercing.
I understand the medical disclaimer that tooth gems are expected to last anywhere between 6 months-several years, without guarantee. It is placed using a semi-permanent dental cement and UV light binder. Gems usually fall off on their own, or can be removed by a dental professional. We do not remove them and we are not responsible for the removal of the gem or any residual cement that may need to be filed off by a dental professional. Figure 8 Ink Studios cautions their clients to research the procedure before commitment, and proceed at your own risk; and although no dental complications are expected, we are not responsible for any related dental work or damage to the teeth of any kind. We use the highest quality gems and equipment, which can be reviewed in depth on Twinkles.net.
I AFFIRM TO THE BEST OF MY KNOWLEDGE that I & members of my immediate family (&/or household), are not currently sick with Covid-19 & in the last 30 days: have not been sick, have not been in contact with anyone that is sick, & have not travelled outside of the country. I UNDERSTAND Figure8Ink has put additional protective measures in place in order to further minimize the risk of exposure to any contamination, virus, or pathogen. I also understand it impossible to completely eliminate that risk. I UNDERSTAND I WILL BE TATTOOED using appropriate sterile instruments & aseptic technique. To ensure proper healing of my tattoo/piercing & to prevent contracting any type of infection or illness (including, but not limited to MRSA & COVID-19), I AGREE to stringently follow the aftercare suggestions outlined in the written tattoo aftercare instructions provided to me until the healing process is complete. I UNDERSTAND that a tattoo usually takes 2 weeks or longer to heal. I UNDERSTAND that getting tattooed/pierced does temporarily stress the body and the immune system, which could make me more susceptible to illness & infection. I ACCEPT THIS RISK.

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 identified as the form for your specific artist, PERI DOUGLASS, please except this as her electronic signature with the understanding that she will read and understand your responses before tattooing. Please let us know if you would like a printed copy of this document. *

Returning Client/ Piercings

Health and Safety Section

General Piercing Release Form Information

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