Download Ear Piercing

Client Consultation Form – Ear Piercing
College Name:
Client Name:
College Number:
Address:
Student Name:
Student Number:
Profession:
Date:
Tel. No: Day
Eve
PERSONAL DETAILS
Age group: Under 20
20–30
Lifestyle: Active
Sedentary
Last visit to the doctor:
30–40
40–50
GP Address:
Have your ears been pierced previously? No
50–60
Yes
CONTRAINDICATIONS (select if/where appropriate):
Fever
Any form of infectious disease
Under the influence of recreational drugs or alcohol
Diarrhoea and vomiting
Cuts and abrasions to the ear/lobe
Bruises to the ear/lobe
Inflammation to the ear/ lobe
Moles on the ear/lobe
Warts on the ear/lobe
Scar tissue (2 years for major operation and 6 months
for a small scar)
Severe skin conditions
60+
If yes how long ago:
Diabetes
Keloid scar tissue
Ear infection
Cardio-vascular conditions
Dysfunction of the nervous system
Nervous/Psychotic conditions
Allergies to metals
Epilepsy
Bells Palsy
Inflamed nerve of the face, head or ear
Recent operations on the face, head, neck or ear
Recent injury to the ear/lobe
Treatment Details:
Client Feedback:
Aftercare and Homecare advice:
Photographic Evidence:
Student/Therapist Signature………………………………
Client Signature……………………………………………...
Parent/Guardian Signature (if under 16 years of age)…………………………………………….
Version 2