Gateways Night and Day Pharmacy



Gateways Night and Day Pharmacy

Request to pierce ears - MINOR

In consideration of Nick Ng, Gateways Night and Day Pharmacy, Gateways Shopping Centre, Wentworth Parade, Success, in the State of Western Australia, and any employee or agent of that pharmacist all of whom are herein after called (‘the pharmacist’) agreeing to perform an operation to pierce my ears and to supply the studs in connection therewith,

I _____________________________________________________________

Of ___________________________________________________________

______________________________________________________________

Being the Parent/Guardian (delete whichever is inapplicable)

Of ___________________________________________________________

Do hereby give permission for him/her to have ear piercing.

I also confirm that both the Client and I on behalf of the Client:

(1) Consent to the undertaking of the operation by the pharmacist;

(2) Have been advised by the pharmacist that the Client’s ears should not be pierced if the Client suffers from any medical disorder or disease which may be affected by ear piercing, including any disorder to the car lobe, ear infection, any serious bleeding disorder, heart disease or diabetes and I hereby warrant to the pharmacist that the Client does not suffer from any such disorder or disease;

(3) I have been provided with appropriate written and verbal instructions on the care of my pierced ears following the operation;

Dated ___________________________________________________

Signed _________________________Witness __________________

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