Online Medical Consent Form
Medical ear piercing
Name (person getting piercing)
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Date of Birth (person getting piercing)
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Month
-
Day
Year
Is this person over 2 months old? Required for piercing at Health Suite 110
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Please Select
Yes
NO
Please describe where you would like your ear piercing
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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.
Who would you prefer to perform your ear piercing?
Please Select
Dr. Megan Groves
Dr. Jennifer Teegarden
Dr. Kylie Vannaman
No preference
Please choose your piercing stud from pictures below. Piercing stud will be in place for 6-12 weeks, depending on location of piercing.
Please Select
Crystal (medical plastic)
Rose (medical plastic)
Violet (medical plastic)
Daisy light fantasy (medical plastic)
Gold & crystal (titanium)
Golden (titanium)
Additional Details
Please review, check each box and sign at the bottom.
*
I understand that if the individual receiving the ear piercing is under the age of 18, a parent or guardian must be present at time of the procedure.
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 and is NOT pregnant.
I understand that ear piercing is a minor surgical procedure with similar risks to stitches and abscess drainage. Despite all precautions taken by Health Suite 110 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 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. Our physicians will do their best to ensure adequate placement of earrings but movement by the patient may affect final placement. If re-piercing is desired, regular piercing fees will apply.
I have read and understand the aftercare instructions and acknowledge that I will be provided 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 since this procedure is done in a medical office, appointments are scheduled in order to best accommodate our patient needs. There is a small chance that my appointment time may require adjustment to accommodate a patient with an urgent/emergent medical need.
I understand that it is recommended that all patients have had at least one round of immunizations, including Hep B and tetanus prior to piercing.
Patient/Parent/Guardian Signature
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Name
*
First Name
Last Name
Relationship to patient
*
"Parent/Guardian" or "Self" if age 18 and over
Email
*
example@example.com
Primary Phone Number
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-
Area Code
Phone Number
Date Signed
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-
Month
-
Day
Year
Submit
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