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PIERCING CONSENT
Use of this form is voluntary and not required by the Department of Health. The form is provided as a service to assist salons in complying with the record-keeping requirements of Chapter 64E-19, FAC.
Name
Name
First Name
Last Name
Address
Address
City
State/Province
Zip/Postal
Physician Name
Physician Telephone Number:
Physician Address: Physician City, State, Zip:
List any allergies you have, including allergies to medications, and allergies to any topical solutions used by this body piercing establishment:
Checkboxes
Description of any Complications during Piercing Procedure

Maximum file size: 268.44MB

Printed Name of Piercer Artist:
Description of Jewelry Used:
Emergency Contact Name:
Emergency Contact Address:
Emergency Contact Phone:
Did you have any bleeding complication?
Body Part Pierced:
Procedure price