Scribd
Upload
187 views2 pages

Consent Form For Ear & Body Piercing - MCMC

This document is a consent form for ear/body piercing from Mami Che's Medical Clinic. It provides information about risks of piercing if the patient has medical conditions like bleeding disorders or is taking certain medications. It also lists potential complications like infection. The patient must confirm they understand these risks and responsibilities of aftercare to give consent for the piercing procedure.

Uploaded by

Darl
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
187 views2 pages

Consent Form For Ear & Body Piercing - MCMC

This document is a consent form for ear/body piercing from Mami Che's Medical Clinic. It provides information about risks of piercing if the patient has medical conditions like bleeding disorders or is taking certain medications. It also lists potential complications like infection. The patient must confirm they understand these risks and responsibilities of aftercare to give consent for the piercing procedure.

Uploaded by

Darl
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

Mami Che’s Medical Clinic

Address: 12 Tarnate St., Talanay Area B, Batasan Hills, Quezon City, 1126
Contact Number: +63915-3173875
Email Address: [email protected]
Facebook Page: https://www.facebook.com/clinicnimamiche/
The care you need, closer to home…

EAR/BODY PIERCING CONSENT FORM

Patient’s Name: _________________________________ Birthday/Age: ___________________ Sex: ___________

I understand that my ears/part of my body will be pierced with:

[ ] pre-sterilized earrings [ ] pre-sterilized piercing needle

I acknowledge that if I am taking blood thinning medications, antibiotics, steroids, or antihistamines, that ear/body
piercing may carry a greater risk for me.

I acknowledge that if I am diabetic, immune-compromised, have high blood pressure, pregnant, have epilepsy, have
hemophilia or other bleeding disorders, or have a heart condition, that ear/body piercing may carry a greater risk for
me.

I understand that ear/body piercing is a minor surgical procedure with similar risks to stitches or abscess drainage.
Despite all precautions that are taken by MC Medical Clinic and my proper following of aftercare, the potential for
infection still exists. There is also a potential that one of the following complications may occur as a result of ear/body
piercing: Persistent redness, swelling, drainage, bleeding, embedded clasp, local infection, cellulitis, blood poisoning
(septicemia), keloids, cauliflower ear, pressure sore, or traumatic injury. (You should contact us if you experience any
of these symptoms)

I have read and understand the AFTERCARE INSTRUCTIONS and have received my copy for reference. Aftercare
of piercing is the responsibility of the patient or parent/guardian once they leave the clinic.

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

I have read and understand all the items listed above and agree to their terms. If the patient is a minor, then the
undersigned certifies to MC Medical Clinic that he/she is the parent or legal guardian of the minor patient named
above.

_____________________________________ __________________________

Signature Over Printed Name Date

_____________________________________

Witness
Mami Che’s Medical Clinic
Address: 12 Tarnate St., Talanay Area B, Batasan Hills, Quezon City, 1126
Contact Number: +63915-3173875
Email Address: [email protected]
Facebook Page: https://www.facebook.com/clinicnimamiche/
The care you need, closer to home…

You might also like