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Consent Form Requirements <br />Health and Safety Code (H&SC) <br />❑ ❑ `Tient 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 />L ❑ 'JDescription of procedure – 119303 (a) 1 <br />❑ ❑ •„Description of what the client should expect following the procedure - 199303 (a) 2 <br />L/Statement regarding permanent nature of procedure – 119303 (a) 3 <br />F F1 Notice that inks are not FDA approved and health consequences are unknown – 119303 (a) 4 <br />Post-procedure hlsh•uctions <br />H&SC 119303 (a) 5 <br />Ill Out / <br />❑ 'Jlnformation 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 />L ❑ /Indications when to seek medical care – 119303 (a) (5) (D) <br />Medical Questiomlaire <br />H&SC 119303 (b) <br />In Out <br />❑ ❑ Tient status regarding pregnancy - 119303 (b) 1 <br />L L —�Iistory of herpes infection at the procedure site – 119303 (b) 2 <br />L1 ❑ 'i'Iistory of diabetes – 119303 (b) 2 <br />LI L \44istory of allergic reactions to latex – 119303 (b) 2 <br />❑ L istory of allergic reactions to antibiotics – 119303 (b) 2 <br />❑ ❑ v listory of hemophilia or other bleeding disorders – 119303 (b) 2 <br />❑1 ❑ NZistory 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 />