Blomdahl Medical Ear Piercing 
This document certifies that the person (or their parent/guardian) listed below has consented to the service of ear piercing by Culver Pediatrics Center on a date to be determined. The service will be performed by a licensed registered nurse. If the person to be tested is a minor, this form must be completed by their parent/guardian.
Please note: For children over 1 year old, we will not pierce their ears if they are crying or upset or fighting the piercer. The child has to assent and consent to the procedure. 
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Today's Date
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Name of Person Completing this Form 
Name of Person to be Pierced
Date of Test (if already scheduled)
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Date of Birth
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Phone Number
Date of Last Tetanus (Tdap or DTaP shot.) of the person to be pierced.  Leave blank if you do not know. We will confirm using CHIRP (Indiana state immunization registry). Infants must have at least two doses of DTaP to be eligible for ear piercing. Children and Adults must have had a tetanus shot within the last 5-10 years. (Note: We can update your Tetanus shot at Culver Pediatrics Center. It takes about 2 weeks for the shot to take effect). 
Payment Preference. Please bring paper or digital copy of your receipt if you paid by Credit Card, PayPal, or Venmo. 
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Name of Parent/Guardian of Person to be Pierced (if person to be pierced is < 18 years)
Click the applicable boxes below if you consent to the Culver Peds staff taking video or photos of the ear piercing procedure to share with you and on their social media and website and marketing. Check all that apply.
By clicking the check box below, you consent for you (or your child listed above) to  receive medical ear piercing by Culver Pediatrics Center on a date to be determined. You acknowledge that the cost of this service is $99  and that Culver Pediatrics Center does not bill insurance. You will receive after care instructions on the day of the ear piercing.  Culver Pediatrics Center offers medical advice, treatment, and management in the rare event of a complication from ear piercing such as allergy or infection within the first 6 weeks after piercing only at no additional cost. In the rare event of a complication such as allergy or infection beyond six weeks, seek medical attention from your primary care physician. 

Culver Pediatrics Center uses the Blomdahl Medical Ear Piercing System which is designed to avoid infections during piercing. The sterile method ensures that the piercing is hygienic and safe. By following the after care instructions, infection from ear piercing with Blomdahl is extremely rare. 

Culver Pediatrics Center uses medical plastic starter earrings which must stay on for 6 weeks. 

Blomdahl’s Medical Plastic is the only ear piercing earring in the world with 0% nickel! This eliminates the risk of developing a nickel allergy. Medical Plastic is recommended for anyone who wants to avoid developing a nickel allergy, for babies and small children, or for anyone that already has a nickel sensitivity. 

By clicking the box below, you consent to and agree to the procedure and the terms outlined in this form. 

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