Permanent jewelry client screening and consent record

Permanent Jewelry | PublicProof Academy working document

Non-editable educational sample of record categories. Not an approved clinical form or treatment protocol. A qualified professional must review suitability before use in their own secure system.

Business

State or jurisdiction

Prepared on

Owner

Official source saved

Next review

Before the welder is switched on

Client name and date
Do you have a pacemaker, defibrillator or any implanted electronic device? YES stops the weld - offer clasp-on instead
Do you have a known metal or nickel allergy or past reaction to jewelry?
Are you pregnant?
Age, and if under 18: parent or guardian present and signature obtained
Skin at the placement site is intact - no cuts, rash, sunburn or recent tattoo

What the client is agreeing to

The chain will be welded closed with no clasp and cannot be removed without cutting
A brief spark and heat occurs at the weld point; a shielding card is placed between the weld and the skin
Small risk of transient redness or a minor burn at the weld point
Metal sensitivity reactions can appear days or weeks later
The chain must be cut before an MRI or surgery and can be re-welded afterwards
Client has been given the aftercare card

Recorded by the operator

Chain style and documented metal
Length welded, in inches
Placement: wrist / ankle / neck / finger
Charms attached
Eye protection worn by operator and client
Tug test performed and passed
Operator name and signature
Price charged and payment method

Use rule: Education and organization only. Record the agency, official source, checked date, cost, proof saved and responsible person for every consequential requirement. Unknown means stop and confirm. Example rows are labeled EXAMPLE and are not your data.