EAR PIERCING CONSENT FORM

PATIENT NAME:

DATE OF BIRTH:

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 ears will be pierced with medical grade sterilized piercing system with earrings chosen at the time of visit.I acknowledge that if I am taking blood thinning medications, antibiotics, steroids that ear piercing may carry a greater risk for me.I acknowledge that if I am 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 for me.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 Balduzzi Pediatrics 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, local infection, cellulitis, keloids, cauliflower ear, pressure sore or traumatic injury.Aftercare of piercing is the responsibility of the patient or parent once they leave the office. AFTER CARE INSTRUCTIONS and product will be given at the time of the visit.I have agreed to this ear piercing procedure, and am fully aware of the potential risks and complications.Ear piercing at Balduzzi Pediatrics does not create a doctor/patient relationship.

I have read and understand all of the items listed above and agree to their terms. If the patient a minor, then the undersigned certifies to Balduzzi Pediatrics that the undersigned is the parent or legal guardian of the minor patient named above.

Signature:

Print Name:

Relationship to Patient: