• Form

  • Bloom Pediatrics and Lactation

    Bloom Pediatrics and Lactation

    Piercing Consent Form
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please state where you would like to be pierced
    For example: both earlobes first piercing/second piercing right earlobe/single cartilage piercing on left ear.

    Reminder that piercing price is as follows:
    $50 for first piercing
    $25 each additional piercing
    $10 for numbing cream

  • 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 ears will be pierced with pre-sterilized, single-use Blomdahl cartridges of medical-grade plastic or titanium. *
  • I understand that if I am taking blood thinning medications, antibiotics, steroids or antihistamines that ear piercing may carry a greater risk.*
  • I attest that to the best of my knowledge, I do not have high blood pressure, epilepsy, hemophilia or other bleeding disorders, a heart condition, or am pregnant. *
  • 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 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/final look. Dr. Hughes 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 my responsibility once I 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 physician 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.*
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  • I have read and understand all of the items listed above and agree to their terms. 

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: