Your Information

All information is private and protected. Used only for your piercing records and aftercare.

Client Age *

Select Minor if the client is under 18 — a parent or legal guardian must be present with valid photo ID.

First Name *

Required

Last Name *

Required

Email Address *

We'll email you your aftercare guide, downsize reminders, and loyalty updates after your visit.

Valid email required

Phone Number *

Valid phone number required

Date of Birth *

Date of birth required

Parent / Legal Guardian Information — required for all minors · must be present with valid ID

Guardian First Name *

Guardian Last Name *

Guardian Phone *

Relationship *

Visit Details

Tell us about your piercing and answer a few health questions. Required by Oregon law (OAR 331-900).

What would you like pierced?

Please select a piercing location

Ear

Ear Lobe

Helix

Daith

Rook

Tragus

Conch

Industrial

Forward Helix

Snug

Nose

Nostril

Septum

High Nostril

Face & Body

Eyebrow

Lip / Labret

Tongue

Navel / Belly

Nipple

Dermal / Microdermal

Oregon Law (OAR 331-900-0100): Nipple piercings are strictly prohibited for anyone under 18 years old, regardless of parental consent.

Promo / Loyalty Code (optional)

Additional Notes (optional)

Health Screening

Required by Oregon State Law (OAR 331-900). Your answers are confidential.

Do you have or have you been diagnosed with hepatitis? Hepatitis B, C, or other forms

Are you HIV positive?

Are you a current IV drug user?

Are you a hemophiliac or have a bleeding disorder? Including those taking blood thinners

Are you allergic to iodine or alcohol? Used in prep and cleaning solutions

Are you currently pregnant?

Have you eaten in the last 4 hours? We recommend eating before your piercing to reduce lightheadedness

Are you taking immunosuppressant medications? e.g. prednisone, methotrexate, cyclosporine, biologics

Do you have physician approval for body piercing while on immunosuppressants?

Please answer all health questions

Release Form & Consent

Please read the release form carefully, then sign below. Required by Oregon State Law.

MULTNOMAH BODY PIERCING — INFORMED CONSENT AND RELEASE OF LIABILITY

STATEMENT OF DISCLOSURE (OAR 331-900-0120)
I understand that body piercing involves puncturing the skin and that there are risks associated with this procedure. I acknowledge that I have been informed of the following:

1. Risks of Infection: Body piercing creates an open wound. Despite sterile technique, there is a risk of local infection, blood-borne disease transmission, and in rare cases, systemic infection. To minimize risk, Multnomah Body Piercing uses single-use, sterile needles and implant-grade titanium jewelry on every piercing.

2. Healing: Healing times vary by piercing location and individual. Cartilage piercings may take 6–12 months. During healing, the piercing may be sensitive, secrete lymph fluid ("crusties"), and may experience temporary redness or swelling. These are normal.

3. Aftercare Responsibility: I agree to follow all aftercare instructions provided by my piercer. I acknowledge that complications arising from failure to follow aftercare instructions are my responsibility.

4. Jewelry: All initial jewelry is implant-grade ASTM F136 titanium — nickel-free and hypoallergenic. I understand that changing jewelry before full healing can cause complications including infection, irritation, and closure of the piercing.

5. Photography: I understand that Multnomah Body Piercing may photograph the piercing process for quality assurance and educational purposes unless I opt out.

6. Refusal of Service: Multnomah Body Piercing reserves the right to refuse service for any reason including but not limited to: intoxication, skin condition at the piercing site, age requirements, or health concerns that may increase risk of complications.

7. Oregon License: Multnomah Body Piercing is a licensed body piercing facility in the State of Oregon. Chris Wheeler holds a valid Oregon body piercing license.

8. Release of Liability: In consideration of the body piercing service(s) to be performed, I hereby release and hold harmless Multnomah Body Piercing, its owners, employees, and agents from any and all claims, losses, or liability arising out of or related to the piercing procedure, provided that proper technique and sterile equipment were used.

9. Minor Consent: If the client is under 18 years of age, the parent or legal guardian signing this form certifies that they are the legal parent or guardian of the minor and that they consent to the piercing procedure. Both the minor and the guardian must be present at the time of service.

10. Accuracy: I certify that all information provided in this intake form is true and accurate to the best of my knowledge. I understand that providing false information may result in refusal of service and/or complications from the procedure.

By signing below, I confirm that I have read and understood this disclosure statement, that I am 18 years of age or older (or that I am the parent/legal guardian of the minor client), that I consent to the piercing procedure, and that I agree to the release of liability stated above.