Consent

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PDP’s Ear Piercing and Aftercare Consent, Waiver, and Release Form
I, the undersigned, give consent for Pixie Dust Piercings (PDP)/Elizabeth, the Piercer, to perform the ear piercings as described on the website. I realize the importance of proper care in permitting the ears to heal without infection. I understand and promise to follow each step of the instructions on PDP's website tab under PIERCING AFTERCARE INSTRUCTIONS. I understand the Piercer will provide me a copy of the aftercare instruction sheet at the time of service. I acknowledge the importance of adhering to these instructions in maintaining healthy ears. Further, I understand that Elizabeth/PCP will not be the one to assess and monitor my daily ear care at home. It is solely my responsibility to strictly follow the aftercare instructions and follow up with an outside medical provider if signs of infection arise.*
I understand ear piercing is a minor surgical procedure with similar risks to stitches and abscess drainage. While the risk of infection from the procedure is extremely low, the potential for complications and infection still exists. There is also potential that one of the following complications may occur as a result of ear piercing: persistent redness, swelling, drainage, bleeding, embedded clasp, local infection, keloids. I will contact my PCP if any of these occur or are suspected to have occurred. I attest that I have provided accurate medical information regarding, but not limited to allergies and medical conditions (past and present) for the person being pierced. If my child is taking blood thinning medications or steroids, ear piercing may carry a greater risk. I will not hold PCP/Elizabeth responsible for any such outcome.*
There is no contraindication for the piercing procedure. I attest to the best of my knowledge my child or I do not have high blood pressure, epilepsy, hemophilia, or other bleeding disorders, a heart condition, or is pregnant. I release my Piercer, Elizabeth, and PDP from any and all liability from this procedure. I understand and promise to carefully follow all instructions on the PIERCING AFTERCARE sheet provided to me and hereby release and forever discharge and hold harmless the Piercer, Elizabeth/PCP, and all its employees, directors, and representatives from any and all claims, damages, or legal actions arising from or connected in any way with my failure to follow all aftercare instructions carefully.*
I understand infant piercings cannot be safely completed until after the first dose of DTaP (diphtheria, tetanus, and acellular pertussis) and the Hepatitis B vaccine. Initial DTaP vaccine usually occurs around 2 months of age. I attest that the Customer named below has had at least both their first DTaP and Hepatitis vaccine and the vaccine was given more than two weeks before the time of piercing.*
By signing below, I give consent to piercing. I understand this type of piercing usually takes 12 months or longer to heal. I hereby release and forever discharge and hold harmless Pixie Dust Piercings, the Piercer, and all affiliates, Owners, Managers, and Employees from any and all claims, damages, or legal actions arising from or connected in any way with my piercing, or the procedure and conduct used in my piercing, to the fullest extent allowed by the law. I attest that I have read and agree to the terms outlined in the above waiver. By signing below, the Customer understands that despite PDP’s best efforts, there is a risk of infection, allergy, or imperfect placement. The Piercer, Elizabeth, or Pixie Dust Piercings will not be held liable for any such outcome. I agree to release and forever discharge and hold harmless the Piercer, Elizabeth/PDP, and all its employees, directors, and representatives from any and all claims, damages, or legal actions arising from or connected in any way with the ear piercing or the procedure and conduct used in the piercing. I specifically acknowledge I have been advised of the facts and all matters set forth above on this consent form and I agree to the terms.*
I grant permission and consent to PDP for the use of the close-up photograph of the piercing (not of the recognizable face) completed for presentation under any legal condition, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content. I understand this release will have no payment, royalties, or revocation.*
I consent to have the optional topical lidocaine cream before my piercing today. I/my minor have no allergy to this product. I understand the numbing cream, only works on the superficial layer. By signing, I acknowledge that I understand the risks and benefits of topical lidocaine, have no allergy to product, and wish to proceed with the application. I will not hold PCP/Elizabeth liable for any negative outcome by choosing to use this product.*
I agree that I am 18 years or older or am providing consent for myself/my child to receive service. I will confirm piercing placement and agree to communicate and make the necessary changes prior to my piercing procedure. I understand that if I am not happy with my piercing for any reason I will let my Piercer know prior to leaving the appointment. Pixie Dust Piercings will not be held liable for any destroyed, damaged, missing, or loose jewelry after this appointment. I agree to, accept, and honor all of the above terms and conditions.*
Please keep in mind our 24-hour cancellation policy. I understand sickness and emergencies do occur. Because it is difficult to fill a canceled appointment without sufficient notice, appointments canceled without 24-hour notice will be charged a fee of $50.00*
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