Consent for Ear Piercing

Please initial the following:

I understand that my ears will be pierced with pre-sterilized, single-use ear piercing earrings.

I have read, and understand the AFTER CARE PROCEDURES and have received a copy for my reference. I understand that aftercare is solely my responsibility and that UPA will not monitor it.

I have agreed to this ear piercing procedure, and am fully aware of the potential risks and complications.

I understand that Universal Pediatrics takes great care to ensure a safe and clean ear piercing experience and is not responsible for any complications that occur outside their office.

I agree that the placement of the earrings (via surgical pen) is agreed upon and approved by the client and/or client’s guardian before the piercing takes place.

My child is at least 2 months of age and has received his/her first primary immunizations including DTaP.

The undersigned, acknowledge that they are aware that ear piercing may carry some risks. These risks include but are not limited to, infection, metal sensitivity, allergic reaction, inflammation, embedding, scarring, fainting and other complications.

If under 18 years old, parent or legal guardian signature is required. Original consent will be kept on file at UPA.