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Minor Piercing Consent Form

Parent/Legal Guardian Federal/State ID

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Minor Federal/State ID or Birth Certificate

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FL DOH Minor Piercing Consent Form

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Client Info

Physician Info

The Florida Department of Health requires each potential piercing client to provide basic physician information to be used as a reference. If you would like to use your own physician information, type "Yes" in the following box and provide it in the boxes below. If you don't have physician information, please type the word "No" in the box below. By typing "No" in the box provided, you are allowing Studio B to provide the Florida DOH with information for Patient's First, the urgent care up the road. That information will be "Patient's First 1600 West Tennessee Street Tallahassee FL, 32304        (850) 359-9307"

Would you like to provide your own Physician Information?

Type "Yes" or "No" Below

Parent or Legal Guardian's Info

List any allergies the client has below, including allergies to medications and allergies to any topical solutions used or may be used by this piercing establishment.

(You may inquire beforehand with one of the piercing staff if you have a question about which may be used in the piercing.)

List, if any, bleeding disorders you or a person in your family has a history of.

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Prior to my piercing:

  •  I received verbal information about the following and discussed it with the piercer or the establishment operator:

  1. A brief description of the piercing procedure;

  2. Any precautions for me to take before the piercing;

  3. A description of the risks and possible consequences of body piercing services;

  4. Instructions for care and restrictions following the procedure;

  5. Restrictions against piercings of minors(if applicable).

  • If the piercing client have diabetes, epilepsy, hepatitis, hemophilia, HIV/AIDS, or any other communicable disease, heart condition, or take medicine that thins the blood, I HAVE/WILL advise the piercer.

  • If the piercing client is under the influence of drugs or alcohol, I HAVE/WILL advise the piercer.

  • If the piercing client is pregnant, I HAVE/WILL advise the piercer

  • If the piercing client has a medical/skin condition such as but is not limited to: acne, scarring eczema(keloid), psoriasis, freckles, moles, or sunburnt skin where the piercing is to be placed, I HAVE/WILL advise the piercer.

  • If the piercing client has an infection, rash or outbreak ANYWHERE on their body, I HAVE/WILL advise the piercer.

  • I understand any skin treatment, laser hair removal, plastic surgery or other skin altering procedures may result in an adverse change to the piercing the piercing client receives today.

  • I acknowledge that a piercing is a SEMI-permanent change to the piercing client's outer body appearance and that no representations HAVE/WILL be made to later change or remove the piercing. To my own knowledge, I do NOT have a physical, mental, or medical impairment or disability which might affect my well-being as a direct or indirect result of my decision to have a piercing performed on the piercing client.

  • I acknowledge I am at least 18 years old and I have truthfully informed the piercer that obtaining this piercing is by a choice between myself and the piercing client and our choice alone. I consent to the application of the piercing and to any action or conduct of the representatives and employees of Studio B that are reasonably necessary to perform the piercing properly. 

  • I acknowledge by signing this form and going through the piercing process, myself and the piercing client wave the right to take legal action against Studio B as a company, the piercer performing the procedure, or any other employable entity hired by/through Studio B.

  • I acknowledge that all of the information provided above was done so accurately and truthfully.

STOP!!!

YOUR PIERCER WILL FILL OUT THE FOLLOWING INFORMATION BELOW

PLEASE DO NOT CONTINUE

ONCE THE INFORMATION BELOW IS FILLED OUT, YOUR PIERCER WILL REVIEW IT WITH YOU PRIOR TO THIS CONSENT FORM BEING SUBMITTED. 

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