Ear Piercing: Daisy Rose Crystal

Ear Piercing: Daisy Rose CrystalMichael Linck2017-06-02T08:49:23-05:00

Patient Information
Name of Patient*
First Last
Date of Birth*
Earring Selection
Daisy Rose Crystal 5mm (P0034/12-0114-42)*
Price: $99.00
Parental / Legal Guardian Information
Name of Parent or Legal Guardian*
First Last
Relationship to Patient*
- Mother
- Father
Email*
Enter Email Confirm Email
Parental / Legal Guardian Consent
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*