Consent Form

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Is this a pre booked appointment?*

Yes

Appointment ID

If you have received your appt ID email, then please copy and paste it here, otherwise just leave it blank. Thanks!

Are you 16 years or older?*

If you are the parent signing the form, please check No!

Yes

This document must be filled and signed by a Mother/Father/Legal Guardian in order to be valid

CONSENT TO APPLICATION OF TATTOO OR PIERCING AND GENERAL RELEASE OF ALL CLAIMS

What do you want?*

Piercing

Tattoo

What do you want?*

Piercing

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TATTOO

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PIERCE

Tattoo Artist Name*

Piercer Name*

Custom Artist Name*

Body Part*

CLIENT MEDICAL HISTORY

Do you currently suffer from, or have you ever suffered from any of the following?

Blood Pressure Problems*

Yes

Details

Heart Condition/Angina*

Yes

Details

Allergies*

Yes

Details

Epilepsy/Seizures*

Yes

Details

Haemophilia/Blood Clotting Disorders*

Yes

Details

Blood borne Virus, e.g. Hepatitis B/C or HIV*

Yes

Details

Skin Complaints, psoriasis, eczema, dermatitis*

Yes

Details

Diabetes*

Yes

Details

Are you prone to fainting and/or feeling light headed/dizzy?*

Yes

Details

Do you regularly take any blood-thinning medicines, e.g. aspirin?*

Yes

Details

Do you take any regularly prescribed medication?*

Yes

Details

Could you be pregnant and/or breastfeeding?*

Yes

As stated on our website, we are unable to pierce or tattoo anyone who is pregnant or breastfeeding.

Child/ward's Details

Child/ward's Name*

First Last

Birth*

Parent/guardian Details

Client Details

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Section Break

Name*

First Last

Preferred Name

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Full Name*

Birth*

Address*

Street Address City ZIP / Postal Code Country

ID Type*

ID Number*

Please note this is not your appointment ID.
If this is a UK drivers license the ID number is the 5th line down, starting with your surname.
If this is a UK passport this is on the top right hand of your photo page under passport number.
If you leave this blank you will be asked to refill in the form

ID Validation*

I agree to bring the same ID used to complete this consent form. I am aware that failure to produce it on the day of the procedure will result in not being able to get your tattoo or piercing.

I agree

Terms*

I confirm that I am legally responsible for the above named minor and take full responsibility for bringing him/her to get a piercing at Studio XIII Gallery. I release Studio XIII Gallery and its employees and agents from all manners of liabilities, claims, actions and demands in law or in equity past, present or future.
I confirm that my child/ward is of sound health both mentally and physically and agree to him or her getting pierced at Studio XIII Gallery.
I confirm that my child/ward is not under the influence of alcohol or drugs.
I confirm that all the medical questions have been answered truthfully.
I confirm that I understand how to take care of my child’s/ward’s piercing and take full responsibility of all aftercare.
I consent to having Studio XIII Gallery collect my information.
For more info check our privacy policy where you’ll get more info on where, how and why we store your data.

I agree

Email*

Phone*

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How did you hear about us?

optional

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Stay in touch with us and subscribe to our newsletter?

Yes

This document must be filled and signed by a Mother/Father/Legal Guardian in order be valid

I acknowledge by signing this consent and release form that I induce STUDIO XIII and to PIERCE my child/ward’s . I confirm I have read the above statement and agree with the stipulations listed and have supplied suitable ID on request as noted.

I confirm that my child/ward is of sound health both mentally and physically and agree to him or her getting pierced at Studio XIII Gallery.

I confirm that my child/ward is not under the influence of alcohol or drugs.

I confirm that all the medical questions have been answered truthfully.

I confirm that I understand how to take care of my child’s/ward’s piercing and take full responsibility of all aftercare.

Full Name:

Date of Birth:

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U16 Name

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U16 Date of Birth

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child/ward's

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CHILD/WARD'S DETAILS

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PARENT/GUARDIAN DETAILS

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CLIENT DETAILS

Almost Done

Hit submit and you will be redirected in order to digitally sign the consent form