Ear Piercing Consent Form

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Home Phone*
Work Phone
Date of Birth*
MM slash DD slash YYYY
Please indicate whether you are currently, or have previously, suffered from the following:
Allergies*
- Yes
- No
Diabetes*
- Yes
- No
High/low blood pressure*
- Yes
- No
HIV/Hepatitis*
- Yes
- No
Epilepsy*
- Yes
- No
Hemophilia*
- Yes
- No
Heart condition*
- Yes
- No
Skin conditions such as psoriasis*
- Yes
- No
Immuno-compromising condition*
- Yes
- No
Are you, or do you suspect that you are pregnant?*
- Yes
- No
Are you currently taking any blood thinning medication?*
- Yes
- No
Are you currently taking steroids?*
- Yes
- No
Are you currently taking antihistamines?*
- Yes
- No
If you have answered YES to any of the above questions, treatment may be refused and you may be asked to contact your Doctor for advice.
Please check the following:*
- Ear piercing will be carried out using an earpiece gun and pre-sterilized earring cartridge. No form of anesthetic will be used.
- New piercings are susceptible to infection until healed. Aftercare of the piercing is the responsibility of the client once they leave the salon. Clients are advised to follow the written aftercare advice provided.
- Swelling, pain and infection are not a normal reaction to piercing and should be referred to your Doctor should they occur.
- Risks associated with any piercing include blood poisoning (septicemia), localized infection, swelling, trauma and scarring.
Please check the following:*
- I understand that my ears will be pierced with pre-sterilized, single use ear piercing earrings that are sealed and packaged.
- I acknowledge that if I am taking blood-thinning medications, have diabetes, am pregnant, a history of medical problems, ear piercings may carry a greater risk, and therefore I must consult a Doctor before getting my ears pierced.
- I have read and understand the aftercare procedure and received a copy for my aftercare reference and that it is my responsibility to follow the aftercare procedures provided at the time of the ear piercing.
- FOR EAR CARTILAGE PIERCING ONLY (not available for children under 13): I understand and accept that ear piercing of the cartilage may carry a greater risk of redness, swelling, local and systemic infection, permanent scarring, the potential of cartilage deformity, and may take substantially longer to heal. Some infections can be caused by pseudomonas aeruginosa or other antibiotic resistant bacteria.
- I confirm that I give my consent to carry out earlob piercing and that the information given above is correct to the best of my knowledge and I will have regard for the verbal and written aftercare advice given to me
Signature
Guardian
Signature of Parent/Guardian is under 16
Name
This field is for validation purposes and should be left unchanged.

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