Consent Form

Client Information

Full Name *

Date of Birth *

Street Address *

City

County

Post Code

Phone Number *

Email *

Emergency Contact Information

Full Name *

Relationship *

Phone Number *

Health Information

Are you currently under the influence of alcohol or drugs? *YesNo

Are you pregnant or nursing? *YesNo

Do you have any allergies (including latex or metals)? *YesNo

If yes, please specify *

Do you have any medical conditions that could affect the healing process (e.g., diabetes, heart conditions, hemophilia)? *YesNo

If yes, please specify *

Are you currently taking any medications? *YesNo

If yes, please specify *

Do you have a history of keloids or problematic scarring? *YesNo

Acknowledgment and Consent

I acknowledge that I have been given the full opportunity to ask any and all questions which I might have about obtaining a body piercing from Valhalla Garden. All of my questions have been answered to my satisfaction. *Yes

I confirm that I am not under the influence of alcohol or drugs and that I am voluntarily submitting to body piercing without duress or coercion. *Yes

I understand that body piercing involves the risk of infection, scarring, and other complications. I have been informed about the risks associated with body piercing. *Yes

I agree to follow the aftercare instructions provided to me until healing is complete. I understand that improper aftercare may result in complications. *Yes

I have truthfully disclosed all health information requested in this form. I understand that withholding any medical information may increase the risks associated with body piercing. *Yes

I release and forever discharge Valhalla Garden and its employees from any and all claims, damages, or legal actions arising from or connected in any way with my body piercing or the procedure and conduct used in my body piercing. *Yes

I acknowledge that the body piercing procedure can only be performed on individuals who are 18 years of age or older. I confirm that I am at least 18 years old, or if I am under 18, I have provided a signed and notarised consent from my parent or legal guardian and they will be present. *YesPlease bring with you your ID at the time of an appointment.

I give my consent to Valhalla Garden to use photographs of my piercing for marketing and promotional purposes. *YesNo

Signature

Client Full Name *

Date *

Parental/Guardian Consent (for clients under 18)

Full Name

Thank you for choosing Valhalla Garden for your body piercing needs. Your safety and satisfaction are our top priorities.

Please check this box to allow us to use any videos or photos on our social media accountYes, I agree

Risks And Side Effects

As with any procedure there are potential risks and complications associated. I confirm that potential complications, example: infection and swelling, gum or tooth damage, jewellery migration/embedding for the procedure undertaken, and aftercare instructions have been explained to me.

I have been advised of the relevant information associated with this treatment and I confirm that I fully understand this advice.

This includes advice about:

the aims/motivations for having the procedure and the desired outcome
the risks inherent in the procedure
the risks inherent in refusing the procedure
the risks specific to me
the expected benefits of the treatment
the potential disadvantages of the treatment
alternative procedures and their pros and cons – including the option of no treatment at all
any uncertainties about and the likelihood of success of the procedure
any follow-up treatment that may be required

CLINICAL PHOTOS AND VIDEOS: I agree to and authorise the taking of clinical photographs and videos. I understand that these clinical photographs and videos will form part of and will be kept with my confidential medical records.

I have been asked what information I want and would need in order to make an informed decision. I have been given the opportunity to discuss my desired outcome fully in order for me to make an informed decision.

I certify that I have read the above consent and that I fully understand it. I have been given ample opportunity for discussion and all my questions have been answered to my satisfaction. No new information has become available that affects my decision to have the treatment or my decision to consent. I hereby consent to this procedure. This constitutes the full disclosure and supersedes any previous verbal or written disclosures.

Client Information

Emergency Contact Information

Health Information

Acknowledgment and Consent

Signature

Parental/Guardian Consent (for clients under 18)

Risks And Side Effects

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Consent Form

Client Information

Emergency Contact Information

Health Information

Acknowledgment and Consent

Signature

Parental/Guardian Consent (for clients under 18)

Risks And Side Effects

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