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 the patient's ears will be pierced with pre-sterilized, single-use Blomdahl cartridges of medical-grade plastic or titanium.
I understand that if the patient is taking blood thinning medications or steroids that ear piercing may carry a greater risk.
I attest that to the best of my knowledge, the patient does not have high blood pressure, epilepsy, hemophilia or other bleeding disorders, a heart condition, or is pregnant AND that the patient 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 and abscess drainage. Despite all precautions taken 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 the primary care doctor of the patient 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. Couturier 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. Couturier 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.
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 Up North Pediatrics/Dr. Couturier that the undersigned is the parent or legal guardian of the minor patient named above.