Riviera ENT Ear Piercing Intake and Consent Form
Patient's Full Name
Patient's Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Patient's Phone Number
Parent/Guardian Full Name for Minor Child- write "N/A" if not applicable
Please upload Photo ID of Patient/Guardian/or Parent
Has the patient had ear piecing before?
If there was prior piercing, were there any problems after?
The piercing site got infected but the earring site healed and is still usable
The piercing site got infected and the earring site closed over
The piercing site got infected and a surgical drainage or earring removal procedure was required
A keloid scar developed
Does the patient have any known allergy to metals?
Which Type of Earring would you prefer (Ear Piercing Gun Options)
24k Gold Plated
Would like to choose in person
Which Type of Earring would you prefer (Ear Piercing with Piercing Needle)?
Cubic Zirconia (Silver)
Cubic Zirconia (Gold)
Cubic Zirconia (Rose Gold)
Synthetic (Plastic Hypo-Allergenic)
Would like to choose in person
If a baby or child, have they received the first round of immunizations yet?
If the first round of immunizations haven't been received, when are they scheduled to take place?
Please check or list all medical conditions the patient has:
High blood pressure
Please clarify any health conditions here if needed:
Please check EACH of these boxes to indicate you understand and consent to the ear piercing:
I understand that fees for ear piercing will not be filed against any insurance. All payments for this service are due at the time of the visit.
I understand that my (or my child's) ears will be pierced with pre‐sterilized, single use gold plated or titanium or stainless steel earrings.
I acknowledge that if I am (or my child is) taking blood thinning medications, antibiotics, steroids, or antihistamines that ear piercing may carry a greater risk.
I acknowledge that if I am (or my child is) diabetic, immune‐compromised, have high blood pressure, am pregnant, have epilepsy, have hemophilia or other bleeding disorders, or have a heart condition that ear piercing may carry a greater risk.
I understand that ear piercing is a minor surgical procedure with similar risks to stitches or abscess drainage. Despite all precautions that are taken by Riviera ENT and my proper following of aftercare, the potential for infection still exists. There is also the 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 (septicemia), keloids, cauliflower ear, pressure sore or traumatic injury. **You should contact the practice if you experience any of these symptoms.
I have read and understand the AFTER CARE INSTRUCTIONS and have received my 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 have read and understand all of the items listed above and agree to their terms. If the patient is a minor, then the undersigned certifies to Riviera ENT that the undersigned is the parent or legal guardian of the minor patient named above.
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