YP Jewelers Ear Piercing Consent Form

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if under the age of 18, fill out in person with parent or legal guardian

Email *

Patient Name *

Nombre de Paciente

Phone Number *

Numero de Telefono

Date of Birth *

Fecha de Nacimiento

YYYY

When do you want to schedule your appointment? (Please allow at least 24 hrs notice before an appointment) *

¿Cuándo desea programar su cita? (Permita al menos 24 horas de anticipación antes de una cita)

YYYY

What TIME do you want to schedule your appointment? *

¿A que HORA desea programar su cita?

Please Check to Indicate Consent *

Marque para indicar el consentimiento

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 ears will be pierced with pre-sterilized, single-use Blomdahl cartridges of medical-grade plastic or titanium.

I understand that if I am taking blood thinning medications, antibiotics, steroids or antihistamines that ear piercing may carry a greater risk.

I attest that to the best of my knowledge, I do not have high blood pressure, epilepsy, hemophilia or other bleeding disorders, a heart condition, or is pregnant.

I understand that ear piercing is a minor surgical procedure with similar risks to stitches and abscess drainage. Despite all precautions taken by YP Jewelers 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 YP Jewelers if any of these occur or are suspected to have occurred.

All questions about the body piercing procedure have been answered to my satisfaction, and I have been given written aftercare instructions for the body piercing I am about to receive.

I have agreed to this ear piercing procedure, and am fully aware of the potential risks and complications.

Required

I have read and understand all of the items listed above and agree to their terms. *

E-Signature (if under 18, must sign in person AND bring a parent or guardian with a valid ID)

A copy of your responses will be emailed to the address you provided.

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