Step 1 of 3 33% LinkedInThis field is for validation purposes and should be left unchanged.Ear Piercing Consent & Booking FormHow to Book Your Appointment Complete the Required Information. Choose your Type of Service and any Add-Ons. Complete the Medical Questionnaire and applicable Consent Form. Click Submit when you are finished. After submitting, you will be directed to Book Your Appointment, where you can select an available date and time. Enter your contact information. Please note: you will need to enter the client name again. As the final step, you will be required to pay a $50.00 deposit. The deposit becomes non-refundable 24 hours prior to your appointment time. Client Name (Person having ears pierced)(Required) First Last Date of Birth(Required)Date of Birth of person having their ears pierced. Please note you will have to reenter on the Booking Calendar. Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Client or Parent/Guardian Photo ID(Required)Upload a picture of your Photo ID (such as Driver's License). For all Clients less than 18 years old, upload parent or guardian's photo ID. No Selfies accepted. Max. file size: 64 MB. Minor's Birth CertificateYou may upload a photo of the child's birth certificate here. Otherwise, you may bring the original document with you for the appointment. *Please note: This is a mandatory item. We will have to cancel your appointment if you forget to bring it to your appointment. The deposit will be non-refundable.Max. file size: 64 MB. Method of Ear PiercingChoose the method of ear piercing you would like. Instrument Piercing. Uses Blomdahl medical grade system. Includes pair of specially designed medical-grade hypoallergenic plastic ear-piercing studs. Jewelry upgrades available. Professional Hollow Needle Piercing. Method used by professional body piercers. Uses implant-grade titanium jewelry. Jewelry upgrade available. Instrument Piercing. ONE Earlobe. $60.00 Instrument Piercing. TWO Earlobes. $99.00 Hollow Needle Piercing. ONE Earlobe. $75.00 Hollow Needle Piercing. TWO Earlobes. $125.00 Ear Piercing Options Enhanced Comfort Option: 6 months or older. Topical anesthetic is applied to help reduce discomfort associated with ear piercing. An assessment will be performed, including a discussion of the risks and benefits of topical anesthetic use. The numbing cream is applied in our office approximately one hour before the piercing procedure. This service is an optional, self-pay service and may not be billed to or reimbursed by the client’s health insurance. TOPICAL NUMBING: After Care Kit: Includes NeilMed Piercing Aftercare sterile saline solution spray (75ml), vegan & preservative free, and 25ea sterile 2x2 gauze. AFTER CARE KIT: Pediatric Service Fee for Children Less Than 6 Years QuantityThis additional fee is for the extra time and care needed for your special little one. Price: $25.00 Quantity Total Medical QuestionnaireMedical Questionnaire(Required)YesNoI confirm that I am at least 18 years of age, or, if I am under 18, that a parent or legal guardian who is at least 18 years of age is providing consent on my behalf.I am currently pregnant.I have a history of herpes infection at the proposed procedure site.I have diabetes.I have allergic reactions to latex or antibiotics.I have hemophilia, a bleeding disorder, or cardiac valve disease.I have a history of medication use and I am not currently using medication, including prescribed antibiotics prior to dental or surgical procedures. List any medications in the section below.I have other risk factors for bloodborne pathogen exposure.Medications(Required)List of medications including any supplements. Type N/A if none taken.Acknowledgements & ConsentBy checking the boxes, I am acknowledging that I have read, understand and consent. Please ensure all boxes are checked or the appointment will be cancelled.Consent:(Required)Consent: I understand that the risk for a tetanus infection is decreased after tetanus immunization. I understand that if the client did not have a Vitamin K injection at birth, or has a bleeding disorder, takes anti-coagulant (blood thinning medication), or an infant who is breastfed, there may be increased risk of bleeding associated with the piercing procedure. I am informed about possible complications of body piercing procedures, such as infection, swelling, scarring including keloids. I understand and agree that it is my responsibility to read and follow the instructions provided about piercing aftercare. I understand that I should consult my doctor before having my ears pierced, if I have any of the following conditions: Contact allergy; Any skin disease such as eczema, psoriasis, seborrheic dermatitis; Diabetes; Infected wounds; Previous problems with wound healing/keloid formation; Heart disease; Antibiotic resistance (MRSA); Belong to an immunocompromised group (incl. pregnancy); Have an implant/prosthesis; High or low blood pressure; Epilepsy or other neurological disease; Hepatitis B, C or HIV; Cysts Consent for Elective Ear Lobe Numbing:(Required)Consent for Elective Ear Lobe Numbing: I acknowledge that the client is at least 6-months of age and does not have eczema, bleeding disorder, congenital heart disease, or an allergy to cetirizine, lidocaine or prilocaine. I understand that mild and transient application site reactions may occur during or immediately after treatment which may include blisters, bruising, burning sensation, depigmentation, dermatitis, discoloration, edema, erythema, exfoliation, irritation, papules, petechial, pruritus, vesicles. I understand that there are risks associated with the topical anesthetic such as allergic reaction and may be life-threatening, including breathing difficulties, lethargy or unresponsiveness which means that I should call 9-1-1 for emergency services. I do not have any known familial hypersensitivity to lidocaine or amide-type local anesthetic. In signing this consent, I assume all risks of loss or injury of any kind whatsoever that may be associated with the ear-piercing and/or topical anesthetic (numbing) procedure and do not hold ZenithMedicine or Dr. Zoe Sun, MD, liable for any injury related to this procedure. By clicking Submit, you agree to allow ZenithMedicine to communicate with you via SMS text messaging and agree to receive text messages from ZenithMedicine. After clicking Submit, you will be brought to our Booking Calendar, where you can select a convenient date and time for your Ear Piercing Appointment. I have read and understand the Piercing Policies & FAQs , which include recommendations regarding preparing for the procedure.
