Ear Piercing Consent

Ear Piercing Consent
PATIENT Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Parent/Guardian Name

First NameLast Name
Phone Number
(Area code) phone number
Address

Street Address

City

Zip Code
Allergies

Other
Medical issues

Other
By signing this consent form, I have read and understand all the items listed and I agree to the terms of this ear-piercing procedure.

I understand that ear piercing is a minor surgical procedure. Despite all precautions taken by Focus Family Medicine and my proper aftercare treatment, the potential for infection still exists. There is also the potential for the following complications with ear piercing: persistent redness, swelling, drainage, bleeding, embedded clasp, local infection, cellulitis, blood poisoning, keloid scarring, cauliflower ear, pressure sore, or traumatic injury.
I agree
Driver's License
Signature (parent or guardian if under 18 yo)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
https://focusfamilymed.com/ear-piercing-after-care-instructions/
Should be Empty: