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In Out <br />In Out <br />In Out <br />Consent Form Requirements <br />Health and Safety Code (H&SC) <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 form — 119303 (a) <br />Description of procedure — 119303 (a) 1 <br />Description of what the client should expect following the procedure - 199303 (a) 2 <br />Statement regarding permanent nature of procedure — 119303 (a) 3 <br />Notice that inks are not FDA approved and health consequences are unknown — 119303 (a) 4 <br />Post-procedure Instructions <br />H&SC 119303 (a) 5 <br />Information of proper care for procedure site — 119303 (a) (5) (A) <br />Restrictions on physical activities — 119303 (a) (5) (B) <br />Signs and symptoms of infection — 119303 (a) (5) (C) <br />Indications when to seek medical care — 119303 (a) (5) (D) <br />Medical Questionnaire <br />H&SC 119303 (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 — 119303 (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 />Form B <br />