Consent & Release Agreement

Relic Moon Fine Jewelry & Body Piercing

Full Legal Name

Date of Birth

Phone Number

Service Type

Health Disclosures (Check all that apply)

Taking blood thinners or bleeding disorders Prone to fainting or dizziness Known metal sensitivities (e.g. nickel) Currently pregnant or nursing

I affirm that I am at least 18 years of age (or have legal guardian present), not under the influence of alcohol or drugs, and consent to the procedure and aftercare protocols.

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Consent & Release Agreement

Release Form Submitted