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Consent Form Requirements <br /> Health and Safety Code <br /> In Out <br /> El Client is at least IS years of age- 119302(a) <br /> NLS 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 /> El Description of procedure-1193 03 (a) 1 <br /> El Description of what the client should expect following the procedure- 199303 (a)2 <br /> El Statement regarding permanent nature of procedure- 119303 (a)3 <br /> Post procedure instructions-119303 (a)4 <br /> information of proper'care for procedure site <br /> restrictions on physical activities <br /> signs and symptoms of infection <br /> indications when to seek medical care <br /> Medical Questionnaire <br /> H&SC. 119303 (b) <br /> n <br /> Out <br /> El Client status regarding pregnancy- 119303 (b) I❑ <br /> History of herpes infection at the procedure site-119303 (b)2 -"'df&J(- <br /> ❑ History of diabetes- 119303 (b)2 <br /> History of allergic reactions to latex- 119303 (b)2 <br /> 11 History of allergic reactions to antibiotics- 1193 03 (b)2 <br /> Y ❑- <br /> History of hemophilia or other bleeding disorders-1193 03 (b)2 <br /> El History of cardiacvalve disease 119303 (b)2 <br /> El Current medications-119303 (b)3 <br /> Requirements for antibiotics prior to surgery or dental procedures- 1193 03 (b)3 <br /> El Other risk factors for blood bome pathogens-1193 03 (b)4 <br /> Form B <br />