Earring Removal Aftercare Form
Please complete the Earring Removal Aftercare Form to confirm you have received aftercare instructions and to report your current post-removal status.
Full Name
*
First Name
Last Name
Date of Earring Removal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where did you have your earrings removed?
*
Which aftercare instructions did you receive?
*
Clean the area twice daily
Avoid touching or twisting the earlobe
Apply a gentle, fragrance-free ointment
Monitor for redness or swelling
Other
How would you describe the appearance of your earlobe(s) now?
*
Normal, no issues
Mild redness or tenderness
Noticeable swelling
Other
Are you experiencing any of the following?
*
Persistent discomfort
Unusual discharge
Increased redness
No concerns
Please share any additional comments or questions about your aftercare experience.
Would you like to be contacted for follow-up?
Yes
No
Email Address (if follow-up is requested)
example@example.com
Submit
Should be Empty: