CUSTOMER RECORD

The following form is required to be filled out by the Florida Department of Health for each person who is getting pierced. Failure to provide the following information can result in refusal of service. For the physician lines, if you do not currently have one or you do not want to provide the information, you may type '911' for each corresponding line. Please submit one form for each peson getting pierced.

First name

Last name

Phone Number

Email

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Address

Emergency Contact City, State, and Zip

Physician Name

Physician Phone Number

Physician Address

Physician City, State, and Zip

Do you have a history of bleeding disorders?

Yes

No

Do you have any allergies including: allergies to medications or any topical solutions used by this body piecing establishment (iodine, latex, etc.)?

Yes

No