👶 Infant & Child Ear Piercing Consent FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Your details - Step 1 of 3Your informationWe use your details to prepare for your appointment, check suitability, record consent and provide aftercare support. Relevant health information is reviewed by your practitioner; you can ask to discuss it privately.Submissions are stored in our website form system. The studio bookings mailbox receives a receipt notification without your health answers or ID documents. Our hosting and email providers help deliver this service. The receipt email sent to you does not include your health answers.For details about your information, retention and your rights, read our Privacy Policy or contact bookings@theviperpit.co.uk. Child's Address Child Parent/Legal Guardian Full Name *Relationship To Child *MotherFatherLegal GuardianSelect your relationship to the child. A parent or legal guardian must attend the appointment.Address *Phone Number *Email Address *Child's Full Name *Child's date of birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Enter the date as DD/MM/YYYY.Procedure Placement Area *Piercer performing the service *ChrisWas your appointment booked or a walk-in? *Please select an optionBooked in advanceWalk-in (no advance booking)Next: healthPermission to use health information *I explicitly consent to The Viper Pit collecting, using and storing the relevant health information I provide about my child to assess suitability, provide the procedure and aftercare, and keep the associated consent record.You can withdraw this permission by contacting the studio. If you prefer not to provide health information online, contact us before submitting to arrange a private discussion. We may be unable to proceed without the information needed for a safe assessment.Child's health information *DiabetesEpilepsy, fainting, seizuresHeart conditionsSkin conditionsBlood-borne virusesBlood-thinning meds, antibioticsAllergies: ink, metals, latex, plasters, lidocaineNone of the aboveI would prefer to discuss relevant health information privatelySelect all that apply. Select 'None of the above' only if no listed condition applies. If you prefer to discuss privately, speak with the practitioner before any procedure.Anything else we should knowWas the Child Born PrematureYesNoBackNext: consentI confirm that:I am the parent or legal guardian of the child named aboveI have full authority to give consentAll information provided is true and accurateI give permission for ear piercing to be carried out at The Viper Pit Tattoo Studio.Parent or legal guardian declaration *I confirm I am the child's parent or legal guardian, have authority to give consent, and have provided accurate information.Procedure UnderstandingI understand that:The procedure involves piercing the ear using sterile, single-use equipmentThe child may experience brief pain, redness, or swellingThere is a small risk of infection, irritation, or allergic reactionJewellery used is suitable for initial piercingPlacement Acknowledgement (IMPORTANT)I understand that:The piercer will mark the placement and ask me to approve it at the appointment before proceedingWhile every effort is made to ensure symmetry, perfect symmetry cannot be guaranteedAs the child grows, ear shape and position may change, which may affect the long-term appearance of the piercingAftercare AgreementI understand that:The piercer will provide and explain written aftercare instructions at the appointmentI will follow all aftercare advice providedI understand improper aftercare can lead to complicationsLiability & ResponsibilityI acknowledge that:All reasonable care and hygiene standards have been followedThe studio and practitioner cannot be held responsible for:Infection due to improper aftercareUndisclosed medical conditionsNormal healing complicationsBehaviour & SafetyI understand that:The procedure will only go ahead if it is safe to do soIf the child is excessively distressed or uncooperative, the procedure may be stoppedBefore the appointment *I have read the information above and understand that the piercer will review health information, explain the procedure and aftercare, answer my questions and ask me to approve the marked placement before proceeding.Date Signede.g 03-01-2025BackSubmit Consent Form
