← Pecorino Piercing
PECORINO PIERCING
3949 Highland Dr, Holladay, Utah
Text (646) 279-6510 · pecorinopiercing.com

Consent & Release

Please read this before your appointment. You'll fill it in and sign a printed copy at the studio, with your photo ID. If anything here doesn't make sense, ask — I'd rather explain it than have you sign something you're unsure of.

1 · About you

2 · Health questions

Are you allergic to latex, iodine, chlorhexidine, adhesives, or any metal (including nickel)?If yes, which:Yes No
Have you taken aspirin, ibuprofen, or any other blood thinner in the last 24 hours?Yes No
Have you had alcohol, cannabis, or any other intoxicant in the last 24 hours?Yes No
Have you eaten in the last two hours?Yes No
Do you have a condition that could affect the procedure or healing — e.g. diabetes, lupus, hemophilia or another bleeding disorder, or a weakened immune system?If yes, which:Yes No
Do you have a heart condition, an artificial heart valve, or have you been told to take antibiotics before dental or medical procedures?Yes No
Are you pregnant or breastfeeding?Yes No
Do you form keloids or raised scars?Yes No
Have you ever fainted during a needle procedure, blood draw, or piercing?Yes No
Are you taking any medication, including steroids or acne medication such as isotretinoin?If yes, which:Yes No

3 · Risks you should know about

Piercing is a procedure that breaks the skin. Even when it's done correctly and cared for properly, these can happen:

4 · Please initial each line

Initials

  1. I am 18 or older and have shown valid government-issued photo ID — or I am under 18, getting an ear piercing only, with my parent or legal guardian present (section 6).
  2. I am not under the influence of alcohol or drugs, and my answers in section 2 are true and complete.
  3. I have read the risks in section 3, had the chance to ask questions, and understand them.
  4. The placement and jewelry have been shown to me and I agree to them. I understand the piercer may decline or change a placement if my anatomy won't support it.
  5. I have received written aftercare instructions and understand that healing depends on following them.
  6. If my piercing shows signs of infection or isn't healing normally, I will see a doctor, and I will let the studio know.
  7. I understand a piercing is permanent body modification and the fee is not refundable once the procedure has started.

5 · Release

I am choosing to be pierced voluntarily, with an understanding of the risks above. To the extent allowed by law, I release Pecorino Piercing and its piercer from claims arising from the procedure and its healing, except claims caused by gross negligence or willful misconduct. This form will be kept on file for at least four years, as the Salt Lake County Health Department requires.

Photographs (optional — your choice doesn't affect your piercing)

May the studio photograph the piercing and use the photo, without your face or name, on its website and social media?   Yes No

6 · Parent or legal guardian — under 18, ears only

I am the parent or legal guardian of the client named above. I am present for the procedure, have shown photo ID and proof of my relationship to the client, and I consent to the ear piercing(s) listed in section 1. I have read sections 2–5 on the client's behalf.

Studio use only

Pecorino Piercing · 3949 Highland Dr, Holladay, Utah · Text (646) 279-6510