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Consent Form Requirements <br /> Health and Safety Code <br /> III out <br /> (� [I Client is at least 18 years of age- 1193 02(a) <br /> AA -9-9- Parents/Guardian signature of minor receiving body piercing- 1193 02(b) <br /> CK LI Signature of client agreeing they have read and completed the consent fon -119303 (a) <br /> CK, [I Description of procedure-1193 03 (a) I <br /> ❑ Description of what the client should expect following the procedure- 199303 (a)2 <br /> Statement regarding permanent nature of procedure- 1193 03 (a)3 <br /> IA Post procedure instructions-1193 03 (a)4 <br /> a) information of proper-care for procedure site <br /> C'S�td A. b) restrictions on physical activities <br /> i'0jr- c) signs and symptoms of infection <br /> d) indications when to seek medical care <br /> Medical Questionnaire <br /> H&SC 119303 (b) <br /> In Out <br /> /-\-Y El Client status regarding pregnancy- 119303 (b) 1 <br /> f-D ❑ Histoty of herpes infection atthe procedure site- 119303 (b)2 <br /> El History of diabetes- 1193 03 (b)2 <br /> �] History of allergic reactions to latex-119303 (b)2 <br /> :1 C1 History of allergic reactions to antibiotics- 119303 (b)2 <br /> El 6>?\ History of hemophilia or other bleeding disorders-119303 (b)2 <br /> 11 UHistory of cardiac valve disease 119303 (b)2 <br /> f-V E] Current medications-1193 03 (b)3 <br /> Requirements for antibiotics prior to surgery or dental procedures- 119303 (b)3 <br /> El Other risk factors for blood borne pathogens-1193 03 (b)4 <br /> Form B <br />