Name: Pediatric People
Price range: $

Patient Information

Name of Patient*

First Last

Date of Birth*

Earring Selection

Daisy Alexandrite Rose 5mm (P0029/12-0114-46)*

Price:

Name of Parent or Legal Guardian*

First Last

Relationship to Patient*

Email*

Enter Email Confirm Email

Consent Statement and Acknowledgment of Risks*

By checking this box and signing this document, I consent to ear piercing for the patient listed above. I understand that ear piercing is a minor surgical procedure with similar risks to stitches or abscess drainage. Despite precautions, there is a small chance of infection, scarring or allergic reactions. As some people are prone to scarring, there is a small risk that a person could develop keloid (an overgrown scar) formation at the piercing site.

Earring Placement Consent*

By checking this box, I consent to the placement marked by the medical professional. I understand that the charge to re-pierce is $25 per ear.

Signature of Parent or Legal Guardian*

Date of Signature*