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SR0085254
EnvironmentalHealth
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MARCH
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4100 – Safe Body Art
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SR0085254
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Entry Properties
Last modified
8/11/2023 4:24:45 PM
Creation date
8/11/2023 4:04:51 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
SR0085254
PE
4103
FACILITY_NAME
MASTER YOUR BEAUTY (INSIDE ROMA MEDICAL SPA)
STREET_NUMBER
3031
Direction
W
STREET_NAME
MARCH
STREET_TYPE
LN
City
STOCKTON
Zip
95219
APN
11624006
ENTERED_DATE
5/10/2022 12:00:00 AM
SITE_LOCATION
3031 W MARCH LN SUIT 104S
P_LOCATION
01
P_DISTRICT
003
QC Status
Approved
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SJGOV\cfield
Tags
EHD - Public
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Do you take antibiotics prior to s <br />CONSENT I certify that I am over the age of 1 E <br />receiving the Lip Blush procedure. I have been <br />tattooing as well as the specific procedure to bi <br />consequences of eyeliner and I understand tha <br />procedure, such as: infection, scarring, or incot <br />permanent artd might result to fading in time. I <br />instructions given to me, Any adverse effects d <br />responsibility.II have been advised to do a patc <br />Should I waive for the test, I release the technic <br />procedure. I acknowledge that some changes i <br />plastic surgery or other procedures. I understa <br />procedure are, part of the said procedure. I acc <br />done. The cost for touch-ups after this first pros <br />Signature: <br />or dental proceduresx <br />and not under the influance of drugs or alcohol, and I consent to <br />formed and it was explained to me the general nature of cosmetic <br />performed. I have been informed of the possible risks and <br />there might be complications and consequences associated with this <br />:istant color. I understand that this cosmetic procedure is not fully <br />ave likewise received and will strictly adhere to procedural <br />e to my failure to adhere to the instructions shall solely be my <br />test to identify any allergic reaction to any medicine or anesthetics. <br />an from liability if I develop an allergic reaction to any of the <br />fight not be corrected in case I undergo other laser hair removal, <br />d that photographs taken for comparison of the before and after <br />�t full responsibility for the decision to have this eyeliner procedure <br />:dare are not included. <br />
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