JEWELRY CHANGES/REMOVALS START AT $5

PICTURE OF PHOTO ID NOT A SELFIE!

(e.g. Drivers License, Passport, CWP, Military ID, School ID)

Please take a picture of your Photo ID*

Click to select file

PLEASE ANSWER THE FOLLOWING QUESTIONS SO THAT WE MAY BETTER SERVE YOU

Where did you get pierced?*

Here

How long have you had this piercing?*

Have you eaten within the last 4 hours?*

YES

Have you had any alcoholic beverages in the last 8 hours?*

YES

Are you prone to fainting?*

YES

Are you prone to heavy bleeding?*

YES

Do you have to take antibiotics before seeing the dentist?*

YES

Have you taken aspirin, ibuprofen, or blood thinners within the last 24 hours?*

YES

Do you have a latex allergy?*

YES

Do you have any other allergies?*

Are you pregnant?*

YES

Do you have any other conditions which might affect the healing of this piercing?*

Full Name:*

Please fill in Address: *

Same as above

Phone number: *

Email: *

Date of Birth: *(MM/DD/YYYY)

By signing this form, I induce Elite Body Piercing to stretch or assess my previous piercing, or to insert or remove jewelry into/from my previous piercing, and in consideration of doing so, I hereby release Elite Body piercing and its employees and agents, from all manner of liabilities, claims, actions and demands, in low or in equity, which I or my heirs have or might have now or hereafter by reason of complying with my request to have my piercing assessed, stretched, or to have my jewelry inserted/removed. Aftercare instructions are available at https://www.safepiercing.org/aftercare.php

By my signature below, I give permission for said insertion/removal/stretching/assessment and I further understand that if I give false information or produce false documents stating my name and age to be other than correct, the I am liable for prosecution.

Your Signature*

Click to sign

Please Enter Date*(MM/DD/YYYY)