PHYSICIAN ACKNOWLEDGEMENT FORM

TO BE FILLED OUT BY CLIENT Client’s Name: _____________________________________________________________________________ Street Address: ____________________________________________________________________________ City, State: ________________________________________________________ Zip Code: _______________ Client’s Telephone Number:_________________________________ Client’s Date of Birth: _________________ Piercing To Be Performed: ____________________________________________________________________ Condition That May Affect Healing of Piercing: ____________________________________________________

I have read all aftercare instructions associated with this piercing and have had the opportunity to ask all questions associated with this procedure. I understand that infection is always a risk associated with piercing and the above listed health condition may further increase my chance of infection or complications during the healing process. Should any complications arise, I agree to seek medical attention.

Client’s Signature: _________________________________________________________ Date: ____________

TO BE FILLED OUT BY PHYSICIAN Physician’s Name: __________________________________________________________________________ Street Address: ____________________________________________________________________________ City, State: ________________________________________________________ Zip Code: _______________ Physician’s Telephone Number: _______________________________________________________________

I, the physician of the above patient, understand that the patient intends to have a body piercing performed at Immaculate Piercing. As the patient’s physician I am aware of the above listed health condition and am willing to treat the patient should any complications arise from the aforementioned condition. My willingness to treat the patient should a problem arise, is in no way an endorsement of the practice of body piercing.

Physician’s Signature: _____________________________________________________ Date: _____________