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Search for:
Ear Piercing: Daisy Rose Crystal
Ear Piercing: Daisy Rose Crystal
Michael
2017-06-02T08:49:23-05:00
Patient Information
Name of Patient
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Earring Selection
Daisy Rose Crystal 5mm (P0034/12-0114-42)
*
Price:
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
*
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