Ear Piercing Consent Form

* You will have option to prepay for your piercing below.  Refunds are available if cancelled >24 hours in advance or at the discretion of Dr. Davidson.   You must have email confirmation from Dr. Davidson of your cancellation.  You can email Dr. Davidson (info@litttlevillagepediatrics.com) if a cancellation is needed.  There may be a $5 fee for refunds to help cover credit card fees. 

* If you are LATE to your appointment there is a possibility your piercing will not be completed and you will lose your payment. You will have to reschedule and pay for a different time slot. No refunds are given for no shows or late arrivals. 

* Cash/apple pay/ credit card are acceptable forms of payment day of as well. If paying CASH, leave the EAR PIERCING PAYMENT BOX completely empty below.  Do not click anything in that box.  

* Dr. Davidson will email you to schedule ear piercing after receiving this form.  

* Reminder: Ear piercing is available to anyone 5 years and up.

* Weekends are typically not available to non members.  It does not hurt to ask if that is needed as sometimes Dr. Davidson is in the office for her patients.  There is an additional $50 fee for weekend piercing.  I try to do piercings between 9am-3pm during the week. 

* IF this is a REPIERCING and you can FEEL a small ball/scar tissue in the ear lobe or you can still see a hole, PLEASE email Dr. Risa Davidson (info@littlevillagepediatrics.com) to determine the best option for you and if piercing is available at the office for you. 

Please watch the following videos PRIOR to completing this form and coming to your appointment.  Please feel free to reach out with ANY questions though.  It will be expected that you have watched these videos prior to your appointment with Dr. Risa Davidson.  I will answer any questions you may have but will not go thru the entire piercing process that is shown in these videos. 

1. The Ear Piercing Process with Dr. Risa Davidson. https://youtu.be/ZAjEpStrt-M  

2. Post Piercing Instructions from Dr. Risa Davidson. https://youtu.be/YzTHQamNcnY 

Piercing price is as follows:

$130.00 total for both ears (includes jewelry, procedure, after care cleaning supplies)

$5 numbing cream (optional).  

$40 additional cost for special order earrings (not in stock)

I understand that fees for ear piercing will not be filed against insurance. All payments for this service are due prior to the procedure.  There are no refunds on the procedure. 

I understand that my child’s ears will be pierced with a pre-sterilized, single-use Blomdahl cartridge of medical-grade plastic or titanium that I will decide upon. 

I attest that to the best of my knowledge, my child does not have high blood pressure, epilepsy, hemophilia or other bleeding disorders, a heart condition, or is pregnant AND that my child has had their first set of immunizations over 2 weeks ago. 

I understand that ear piercing is a minor surgical procedure with similar risks to stitches. Despite all precautions taken by Little Village Pediatrics and my proper following of aftercare instructions, the potential for infection still exists. There is also potential that one of the following complications may occur as a result of ear piercing: persistent redness, swelling, drainage, bleeding, embedded clasp, local infection, cellulitis, blood poisoning, keloids, pressure sore, or traumatic injury. I will contact my own primary care physician if any of these occur or are suspected to have occurred.

I understand that there is a chance of cosmetic defect or that I or my child will not like placement. Dr. Davidson will do her best to ensure adequate placement of earrings but movement by the patient may affect final placement.

I have read and understand the Aftercare Instructions and have received a copy for my reference. Aftercare of piercing is the responsibility of the patient or parent once they leave the office.

I have agreed to this ear piercing procedure, and am fully aware of the potential risks and complications.

I understand that Dr. Davidson is not my pediatrician and is not responsible for any complications related to the piercing or otherwise. Any complications that result from the piercing or otherwise will be directed to my own physician.

I have watched the PRE PIERCING video and POST CARE video instructions with my child so we are prepared for the piercing procedure and how to take care of the piercing afterwards. 

I attest that I am the legal guardian for the person getting pierced and am legally able to consent for piercings and procedures on this person.  I understand that as the legal guardian and decision maker I must be present for the piercing. 

I have read and understand all of the items listed above and agree to their terms. If the patient is a minor, then the undersigned certificates to Little Village Pediatrics that the undersigned is the parent or legal guardian of the minor patient named above.