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Consent Form Requirements <br /> Health and Safety Code <br /> it, out <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-1193 03 (a) <br /> El Description of procedure-119303 (a) 1 <br /> 64-11 Description of what the client should expect following the procedure- 199303 (4)2 <br /> O-E] Statement regarding permanent nature of procedure,- 119303 (a)3 <br /> El v64-- Post procedure instructions-1193 03 (a)4 <br /> information of proper care for procedure site <br /> e ' ns on physical activities <br /> i strict'o symptoms <br /> 0 <br /> signs <br /> 11 and pt ms of infection �10 21 <br /> restrictions when to seek medical care <br /> Medical Questionnaire <br /> H&SC, 119303 (b) <br /> In Out <br /> El Client status regarding pregnancy- 119303 (b) I <br /> ❑ History of herpes infection at the procedure site-119303 (b)2 <br /> ❑ History of diabetes- 1193 03 (b)2 <br /> 04- Fl History of allergic reactions to latex-119303 (b)2 <br /> th-- History of allergic reactions to antibiotics- 119303 (b)2 <br /> ❑ �4- History of hemophilia or other bleeding disorders-1193 03 (b)2 <br /> L1 d- 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 home pathogens-119303 (b)4 <br /> A C?- <br /> V\,N- MAC.) OS- Ck <br /> -UNY ft <br /> VTOCcavy-c- sz'Af- , <br /> Iry VY ov- v(LAC rL <br /> 1Oc)e) Lj pe-e,,-1 -Tlf— vy-r <br /> -*\C) <br /> YA <br /> AS <br /> -Y\,f -e& � r t CA� <br /> 40 s, yyvfL <br /> Form B <br />