Health Declaration

What is your relationship with the client? (If not yourself, you must be authorized to make decisions on behalf of the Client) *

Patient's First Name

Patient's Last Name

Date of Birth

Guardian's Full Name

Street Address with Zipcode

Pediatrician's First Name Pediatrician's Last Name Pediatrician's Location - Address

Is the person we are providing service for (the Client) a minor? *

Yes

Any known allergies to metals or plastics? *

Yes

Any personal or family history of keloids? *

Yes

Any trouble with ear piercing in the past? *

Yes

Would you/your child be interested in being featured on our Facebook page?

Yes

How did you hear about us?

Family

Friend

Doctor

Goggle

Facebook

Instagram

Other

Any trouble healing in the past? *

Yes

Any trouble with ear piercing in the past? *

Yes

Redeem Gift Certificate

Yes

Do you have any particular concerns about the procedure?

If you answered yes to any question, please elaborate

I declare that the info I’ve provided is accurate & complete

Sign Here

Phone

Thank You for submitting!

Booking Step 3

Click Button to Pick your Appointment Date & Time

Bergen County, NJ, NYC and Surrounding Areas

Perfect Piercing, NP, or Claire are not affiliated with any other group or business.

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