Ear Piercing Consent for NW Cypress MD

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Ear Piercing Consent

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I understand that fees for ear piercing will not be filed against any insurance. All payments for this service are due at the time of service.

I understand that my ears/my child's ears will be pierced with sterile, medical plastic or titanium earrings.

I understand that ear piercing is a minor surgical procedure and despite all precautions that are taken by NW Cypress Pediatrics and Family Medicine and following the aftercare, the potential for infection and possible keloids still exists.

I have read and understand the aftercare instructions and have received a copy for my reference.

I understand that the ear will be marked for placement of the earring and I agree to this placement.

I understand that if I am unhappy with piercing for any reason afterwards, there is a 25.00 fee to re-pierce each ear if done in the same date of service.

I have agreed to this ear piercing and I am fully aware of possible risks and complications.

I understand that NW Cypress Pediatrics and Family Medicine is not responsible and I hereby release and waive any all claims that I or the minor may make as a result of this ear piercing.

I authorize the use and disclosure of my/my child's photograph to be hung in the facility for marketing purposes by NW Cypress Pediatrics and Family Medicine.

I am the patient or legal guardian of

I have legal right to consent medical and surgical treatment of this patient. I voluntarily authorize and consent to such medical care, treatment, and diagnostic tests that the physicians believe are necessary. I am giving permission for the Doctors and staff of NW Cypress Pediatrics and Family Medicine to provide treatment to this patient as long as I or my child is a patient at the clinic.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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