Consent to Pierce

Her Alibi Salon, LLC

620 N Last Chance Gulch
Helena, Montana
406-442-2452

Ear piercing will be carried out using an ear piercing gun and pre-sterilized earring cartridge. No form of anesthetic will be used. Please initial each provision on the line provided.

Step-by-step guide: complete the boxed area, then the box moves to the next required item. Staff names are required first, then the client initials/signs. Use the Rewrite button under any initials or signature box to clear and sign again.

Procedure Information

The artist will perform the ear piercing.

The procedure listed above will be located on the indicated ear(s).

The procedure will be conducted on the following date:

Does the client meet any condition requiring a written physician referral? Yes No

I have provided a written physician referral because I meet one or more of the following criteria:

I am taking a drug or dietary supplement that induces bleeding tendencies or reduces clotting.
I have a medical condition that is known to cause bleeding tendencies or reduces clotting.
I show signs of intravenous drug use.
I have a sunburn, skin disease such as psoriasis or eczema, skin infection, or lesion such as a mole at the proposed site of procedure.
I have allergies or contact sensitivity to pigments, soaps, or other substances that may be used in the procedure.

Required Disclosures

I understand that my piercing may result in complications and side effects that include: abscesses, allergies, heavy metal poisoning, infection, keloid formation, scarring, swelling, and blood-borne pathogens.

I understand that symptoms of infection may include fever, swelling, redness, drainage, pain, warmth, or unusual symptoms around the piercing site.

If infection or other complications occur, I will consult with a licensed medical provider.

I understand that specific piercings are permanent in nature and may result in permanent scarring or marks.

I acknowledge I will be provided aftercare instructions by both in writing and verbally.

Client Information

Client First Name

Client Last Name

Phone

Date of Birth Age Email

Client Address

Parent / Legal Guardian Consent

Is the client under 18? Yes No

If the client is under 18, the parent or legal guardian must sign in person before the procedure and must be present for the entire procedure.

Parent / Guardian Full Name

Relationship Parent / Guardian Phone

Parent / Guardian Email

Is the client under the age of 3? Yes No

If the client is under age 3, the parent/legal guardian has been given verbal and written warning that jewelry presents an inherent choking hazard before the piercing.

Consent and Signatures

I consent to receiving the procedure listed above. I certify the information provided is true and complete to the best of my knowledge. If the client is under 18, the parent or legal guardian must sign in the space provided in person before the procedure and must be present for the entire procedure.

Client Signature

Parent / Guardian Signature

Client Name Print

Parent / Guardian Name Print

Earring Lot #

Date Signed

After generating the PDF, the completed signed form can be downloaded or shared from the device.

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Your completed piercing consent PDF is ready.

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