Ear Piercing Consent

PATIENT Name*

First NameLast Name

Date of Birth*

MonthDayYear

Parent/Guardian Name

First NameLast Name

Phone Number*

(Area code) phone number

Address*

Street Address

CityState

Zip Code

Allergies*

Medical issues*

By signing this consent form, I have read and understand all the items listed and I agree to the terms of this ear-piercing procedure.*

I understand fees for ear piercing will not be filed with insurance. All payment for this service is due at the time of the visit. Fees are non-refundable once sterile supplies are opened.I understand the patient’s ears will be pierced with pre-sterilized, single-use medical grade earrings.I understand that ear piercing is a minor surgical procedure. Despite all precautions taken by Focus Family Medicine and my proper aftercare treatment, the potential for infection still exists. There is also the potential for the following complications with ear piercing: persistent redness, swelling, drainage, bleeding, embedded clasp, local infection, cellulitis, blood poisoning, keloid scarring, cauliflower ear, pressure sore, or traumatic injury.I agree to seek medical care with my own personal physician for any complications.I understand that there is a chance of cosmetic defect or dissatisfaction with the placement or final look of the piercing.I authorize and approve the location and position of the piercing on both ears.I have read and understand the ATERCARE INSTRUCTIONS and have received a copy (link also below). Aftercare of piercing is the responsibility of the parent or patient once they leave the office.

I agree*

I certify that I am the parent or legal guardian of the minor patient named above or I am eighteen years or older and able to consent for my own procedures.

Driver's License *

Signature (parent or guardian if under 18 yo)*

Date*

Date

https://focusfamilymed.com/ear-piercing-after-care-instructions/