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The Glory Hole Piercing Studio – Fountain, Colorado
Consent
Form
This is where your experience begins, designed to streamline your visit so our focus stays on you, not paperwork.
BODY PIERCING CONSENT FORM
*
Name
Date of Birth
Month
Day
Year
*
Address
*
City
*
Select State
*
Zipcode
*
Email Address
*
Phone Number
*
Check any conditions listed below that apply to you:
N/A
Asthma
Diabetes
Bleeding Disorders
Blood Thinners
Eczema/ Psoriasis
Epilepsy
Faint/ Dizzy
Heart Condition
Hemophilia
Hepatitis
HIV/ AIDS
Herpes
Immune-Compromised Status
Infection(s)
Pregnant or Nursing
Scarring/ Keloids
Skin Boils/ Pimples
Skin Disease/ Lesion
Skin Rash
Sunburn
Tuberculosis
*
Check any allergies or adverse reactions that apply to you:
N/A
Alcohol Based Products
Adhesives
Cotton Products
Disinfectants
Fabric/ Gauze
Iodine
Latex
Lidocaine
Medical Grade Lubricant
Any other allergies, or medications that could interfere with the healing process?
*
Type of Piercing:
Body Piercing
Ear Piercing
Facial Piercing
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The Glory Hole Piercing Studio – Fountain, Colorado
Home
Aftercare
Booking Request
Contact Us
Ear Piercing for Kids
FAQ
The Studio
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