Ear Piercing Consent and Documentation Form

Ear Piercing Information and Consent
Patient Information (Caregiver to complete)
NOTE: All patients receiving an ear piercing must meet the following criteria: (1) At least two doses of DTaP vaccine; (2) Be at least 2 weeks after their second DTaP vaccine; (3) Either be less than 15 months old or over 8 years old
Patient name*
DOB*
Caregiver Name*
Relationship to patient*
Signature of Caregiver*

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Read and check the following items to indicate acknowledgement and agreement (all must be checked and agreed to before scheduling)*

I understand that my child must have at least two DTaP vaccines and be less than 15 months old or older than 8 years old.I acknowledge that ear piercing is a cosmetic, elective procedure and for older children it is required that they agree to have their ears pierced.To safely perform this procedure these children cannot be restrained or immobilized by a parent, legal guardian, or staff member of The Children’s ClinicI understand that fees for ear piercing will not be filed through insurance. All payments for this service are due at check-in and there are no refunds if the procedure is not carried out due to caregiver refusal or child’s refusal.I understand that my child’s ears will be pierced with pre-sterilized equipment: either single use and sterile medical grade Blomdahl cartridges or single use pre-sterilized medical grade needles, cork, and ear ring studs. Only ear lobes will be pierced (no other body parts or cartilage).I understand that the benefit of having this procedure done at a medical clinic is the provider has been trained in and understands proper sterile technique and that sterile tools, gloves, drapes, ear piercing studs, and associated tools/equipment will be usedI understand that if my child is taking blood thinning medications, antibiotics, or steroids there is a greater risk of complications from ear piercing and it is my responsibility to inform the provider performing the piercing if this is the caseI attest that to the best of my knowledge my child does not have high blood pressure, epilepsy, hemophilia (or any other bleeding disorder), a heart condition, diabetes, or is pregnantI acknowledge that a history of allergic reactions to medications, metals, iodine, or other chemicals need to be disclosed prior to the procedure to the providerI acknowledge that pre-procedure numbing medication (cream or spray) or other numbing techniques (ice or frozen object applied to the ear)will not guarantee the patient will not feel the piercing procedureI understand that ear piercing is a minor surgical procedure. Despite all standard precautions being taken by The Children’s Clinic and despite following all proper 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 inflammation or skin discoloration, swelling, drainage, bleeding, embedded clasps, local infection, cellulitis, blood stream infection, keloids, auricular hematoma (cauliflower ear), or pressure sore. I will contact The Children’s Clinic or my child’s PCP if any of these occur or is suspected to have occurred so a regular clinic appointment can be madeI have received a copy of the aftercare instructions (available on thechildrenscliniccg.com) and intend to read these instructions and will ask for any clarification during the visit. Aftercare of piercing is the responsibility of the patient or parent once they leave the officeI have agreed to this ear piercing procedure and am fully aware of the potential risks and complicationsI have read, understood, and agree with all of the items listed above. If the patient is a minor, then the undersigned certifies to The Children’s Clinic, under penalty of perjury, that the undersigned is a legal guardian of the minor patient named above
Caregiver Signature*

Clear
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Patient name
DOB
Ear Piercing Method
Below, choose the desired ear piercing method. Options are the Blomdahl gun or using a hollow needle.

The Blomdahl gun (https://blomdahlusa.com/medical-ear-piercing/) uses pre-sterilized, single-use cartridges and either medical grade plastic or titanium ear rings.

The hollow needle method uses pre-sterilized hollow needles and sterilized ear rings of either surgical grade stainless steel or titanium.

All patients must have two administrations of the DTaP vaccine prior to an ear piercing. For safety, only the following age groups can be considered for ear piercings: less than 15 months of age and over 8 years of age. The Blomdahl gun is appropriate for both age groups but the hollow needle can only be scheduled for 8 years and up. Note: the Blomdahl gun can be used for kids 8 and up as well.

Price listed is per ear and includes after care instructions, sterilized wipes, and a sterilized medical grade ear ring.

Choose between Blomdahl or Hollow needle and the earring type
Blomdahl Method, choose earring type (images below): <15 months of age or over 8 years of age

Medical Grade plastic ear ring, $50/earMedical grade titanium ear ring (gold or silver colored), $55/ear
Hollow Needle Method: 8 years and up only

Implantable Titanium, $55/earGold plated Implantable Titanium, $55/ear
Which Ear lobe (no cartilage)*

Right ear lobeLeft ear lobeBoth ear lobes
OPTIONAL: Numbing cream (lidocaine/prilocaine), $10 extra. Must arrive 30 minutes before appointment for application
Caregiver Signature*

Clear
Date

MonthDayYear
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Should be Empty:

Ear Piercing Information and Consent

Patient Information (Caregiver to complete)

NOTE: All patients receiving an ear piercing must meet the following criteria: (1) At least two doses of DTaP vaccine; (2) Be at least 2 weeks after their second DTaP vaccine; (3) Either be less than 15 months old or over 8 years old

Ear Piercing Method