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` 0 • <br /> Consent Form Requirements <br /> Health and Safety Code <br /> ❑ Client is at least 18 years of age- 119302(a) <br /> ❑ Parents/Guardian signature of minor receiving body piercing— 119302 (b) <br /> ❑ Signature of client agreeing they have read and completed the consent fonn—1193 03 (a) <br /> ❑ Description of procedure— 1193 03 (a) 1 <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 /> ❑ Post procedure instructions— 119303 (a)4 <br /> a) information of proper care for procedure site <br /> b) restrictions on physical activities <br /> c) signs and symptoms of infection <br /> d) indications when to seek medical care <br /> Medical Questionnaire <br /> H&SC 110303 (b) <br /> ❑ Client status regarding pregnancy- 119303 (b) 1 <br /> ❑ History of herpes infection at the procedure site— 119303 (b)2 <br /> ❑ History of diabetes— 119303 (b)2 <br /> ❑ History of allergic reactions to latex-119303 (b)2 - <br /> ❑ History of allergic reactions to antibiotics— 119303 (b)2 <br /> ❑ History of hemophilia or other bleeding disorders— 119303 (b)2 <br /> ❑ History of cardiac valve disease 119303 (b)2 <br /> ❑ Current medications— 1193 03 (b)3 <br /> ❑ Requirements for antibiotics prior to surgery or dental procedures— 119303 (b)3 <br /> ❑ Other risk factors for blood borne pathogens— 119303 (b)4 <br />