Ear Piercing Consent for Non-Member Minor

Patient Name*

First NameLast Name

Date of birth*

Date

Please state where you would like to be pierced blanks *
For example: both earlobes first piercing/second piercing right earlobe/single cartilage piercing on left ear.
*Please note cartilage piercing is only available for those 15 years and older.

Reminder that piercing price is as follows:
$100 for a pair
$50 each additional earring
$10 for numbing cream

Would you like numbing cream?*

YesNo

Initial below each statement to indicate consent:

I understand that fees for ear piercing will not be filed against insurance. All payments for this service are due at the time of the visit.*

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

I understand that if my child is taking blood thinning medications or steroids that ear piercing may carry a greater risk.*

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 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 and abscess drainage. Despite all precautions taken by Bloom Pediatrics/Dr. Hughes 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, cauliflower ear, pressure sore, or traumatic injury. I will contact my own pediatrician 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/final look. Dr. Hughes will do her best to ensure adequate placement of earrings but movement by the patient may affect final placement. *

I understand the Aftercare Instructions and a copy for my reference will be provided at the time of the piercing. 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. Hughes 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 pediatrician or physician.*

We have several piercing studs to choose from! You will pick these out at the time of the appointment. We no longer have images on the forms because inventory is constantly changing. Thank you for being understanding!

Please choose your piercing stud from pictures above. Piercing stud will be in place for 2-3 months, depending on location of 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 Bloom Pediatrics and Lactation/Dr. Hughes that the undersigned is the parent or legal guardian of the minor patient named above.

Signature*

Parent/Guardian Name*

First NameLast Name

Relationship to patient*

Today's Date*

Date

Form

Bloom Pediatrics and Lactation

Address: 2870 W 47th Ave, Kansas City, KS 66103