For Office Use Only

(Printed Name of Licensed Salon)

(Printed Name of Body Piercer)

(Signature of Body Piercer)

State of Florida Department of Health

Chapter 64E-19, Florida Administrative Code

Use of this form is voluntary and not required by the Department of Health. This form is provided as a service to assist salons in complying with the record keeping requirements of Chapter 64E-19, Florida Administrative Code.

Piercing Notarized Minor Consent Form

State of FloridaCounty ofSs:

(Print Name of Parent or Legal Guardian)

Residing at:

Hereby swears or affirms under penalty of perjury, that the following facts as stated in this document are true:

1)I am the natural parent or legal guardian of:

(Print Name of Minor Child)

2)The Minor Child's date of birth is:

(Month)

(Day)

(Year)

3)The child's age is:.

4)I have the legal authority to give consent to the body piercing of this child.

5)I consent to the body piercing of my child as follows:

(location of piercing)

(Signature of Parent/Legal Guardian)

Sworn to, or affirmed, in person before me, thisday of, 20, by

(Print Name)

who is personally known to me, or, who produced satisfactory identification in the form of

Seal:

(Signature of Notary)

(Print Name of Notary)

64E-19, F.A.C.