Ear Piercing Consent Form

* Unfortunately due to the recent number of "no shows" to ear piercing appointments we have had to implement a 24 hour cancellation rule.

* You will 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. 

* If you would like to pay cash please email Dr. Davidson and she can accommodate.

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

* Reminder: Ear piercing is available to anyone 2 months -6 months with their first set of vaccinations OR age 4 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. 

Piercing price is as follows:

$60.00 for 1 ear (lobe) age 4 years and up

$95.00 for 2 ears (lobes) age 4 years and up

$150 for age 2 months-6 months. 

$5 numbing cream (optional). You do not need numbing cream in infants. 

$35 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 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.