Medisept Customer Registration Form

Solution Instructions:

• Normal Solution : 8 weeks, twice a day.
• Advanced Solution : 3 weeks, twice a day.

By signing this form, I certify that I have read and understood the information detailed on the form and that I have read and received a copy of the Aftercare Procedure and understand the risks associated if not faithfully followed. Understanding the risk, I consent to have my ear(s) pierced by an employee of this store. Whilst the store will have liability to the extent that any injury that has been caused by its negligence, I acknowledge and agree that I will be responsible and liable for other injuries caused, including any injuries resulting from any failure to follow the aftercare procedure correctly. If signing as a Parent or Legal Guardian on behalf of a minor, I give all necessary consents to the piercing, accept that it is my responsibility to ensure that the minor is happy with and wants the piercing and acknowledge that it is my sole responsibility to ensure that all aftercare procedures are followed. If a minor is clearly distressed about having a piercing, we will be unable to complete the piercing.

I confirm that I have fully and accurately disclosed all information requested by this form. The information that I have provided is true to the best of my knowledge and I accept full liability for the consequences of any false information that I have provided or information which I have omitted to provide. I confirm that the information provided on the medical history is correct to the best of my knowledge and that I am not currently under the Influence of drugs or alcohol. I give consent to the piercer to retain the details provided on this form in line with local authority regulations.