About Us

First Name

Last Name

Phone *

Date of birth *

Address

Street Address *

City *

State *

Postal code *

What piercing are you getting? *

How did you find us? *

Do you have any allergies?

Yes

Do you have Flu like symptoms?

Yes

Bloodbourne Pathogens

Yes

Influence

I am not under the influence of alcohol or drugs, and I am voluntarily submitting to be Pierced by the Piercier without duress or coercion.

To ensure that your body art procedure heals properly, we ask that you disclose if you have any of the following conditions. Disclosure does not prevent you from having a body art procedure. **Only click the condition you have.**

Diabetes

History of Hemophilia (Bleeding)

History of skin disease, skin lesions or skin sensitivities to soaps, disinfectants, ect

History of allergies or adverse reactions to pigments, dyes or other skin sensitivities such as latex.

History of epilepsy, seizures, fainting, or narcolepsy.

Medications used such as anticoagulants that thin the blood and or interfere with blood clotting.

Human Immunodeficiency Virus (HIV)

Hepatitis

Any other information that would aid us in evaluating your body art healing process.

Photography

I release all rights to any photographs taken of me and the piercing and give consent in advance to their reproduction in print or electronic form. (If you do not tick this provision, please advise your Artist).

Consent

I acknowledge by signing this waiver that I have been given the opportunity to ask any and all questions which I might have about the obtaining of a tattoo or piercing by Midwest Tattoo LLC, DBA The Piercing Boutique and that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below and agree as follows:

I acknowledge that infection is always possible as a result of obtaining a piercing particularly but not limited to the event that I do not take proper care of my piercing.
I acknowledge receipt of verbal and/or written instructions advising me of the proper care of my piercing and further recognize the absolute necessity for following those instructions.
I acknowledge that a piercing is a permanent change to my appearance and that no representations have been made to me as to the ability to later change or remove the piercing.
I acknowledge that I have truthfully represented to the employees, agent, subcontractors, and representatives of Midwest Tattoo LLC, DBA The Piercing Boutique that I am of legal age according to Illinois Criminal Code to obtain services performed at The Piercing Boutique.
I agree to release and forever discharge and hold harmless Midwest Tattoo LLC, DBA The Piercing Boutique employees, agents, subcontractors and representatives from any and all claims, damages, or legal actions arising from or connected in any way with my piercing or the procedures and conduct used to apply my piercing.
I understand that Midwest Tattoo LLC, DBA The Piercing Boutique, its employees, agents, representatives or subcontractors have made no representation about and assume no responsibility for any and all mistakes,I also understand that Piercings, over time, may reject, and or fall out, specifically when located on body parts that move.
I agree whether the information I provide is truthful, or if my signature is or is not applied, that I agree to the terms set forth in the agreement.
I acknowledge that I have seen a physician and have been deemed medically able to get a piercing.
I acknowledge that I have read both sides of this form.
After receiving a piercing, it is recommended that you do not drive if you are feeling dizzy, faint, or lightheaded.

Signature

Clear

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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