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Consent Fonn Requirements <br /> Health and Safety Code <br /> In Out <br /> ❑ 9 Client is at least 18 years of age- 119302(a) <br /> H—PA/A Parents/Guardian signature of minor receiving body piercing– 1193 02(b) <br /> 9 ❑ Signature of client agreeing they have read and completed the consent form– 119303 (a) <br /> ❑ Description of procedure– 119303 (a) 1 <br /> 6 ❑ Description of what the client should expect following the procedure- 199303 (a)2 <br /> ❑ X Statement regarding permanent nature of procedure– 119303 (a)3 <br /> ❑ Post procedure instructions– 1193 03 (a)4 <br /> information of proper care for procedure site <br /> b) restrictions on physical activities <br /> 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 /> C< ❑ Client status regarding pregnancy- 119303 (b) 1 <br /> ❑ V� 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 /> (K ❑ History of allergic reactions to antibiotics– 1193 03 (b)2 <br /> �C ❑ History of hemophilia or other bleeding disorders– 1193 03 (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 />