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SR0084278
EnvironmentalHealth
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4100 – Safe Body Art
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SR0084278
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Entry Properties
Last modified
3/8/2024 11:54:01 AM
Creation date
3/5/2024 9:24:50 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
SR0084278
PE
4103
FACILITY_NAME
SHAUNA HARO BEAUTY / STYLES SALON
STREET_NUMBER
902
Direction
W
STREET_NAME
LODI
STREET_TYPE
AVE
City
LODI
Zip
95240
APN
03308057
ENTERED_DATE
9/28/2021 12:00:00 AM
SITE_LOCATION
902 W LODI AVE
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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SJGOV\cfield
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EHD - Public
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I have been advised that upon completion of the procedure there may be swelling and redness of <br />•ii ;kin, which will subside within 1-2 days dependent on lifestyle. In some cases bruising can occur. I <br />h.ve been advised that I can resume normal activities immediately following the procedure, however, using <br />cc smetics, prolonged exposure to water, excessive perspiration and exposure to the sun should be limited <br />b' i p to two weeks following the infusion process. <br />I understand that immediately after the procedure the enhancement can be 40°x6 to 60°x6 darker than <br />th3 desired result and can take between 4-10 days to lighten. I understand that the true color will be visible <br />1 ronth after each application, and that the color may vary according to skin tones, skin type, age and skin <br />conditions. I appreciate that some skins accept color more readily than others and no guarantee of an ex- <br />act effect or color can be given. <br />I agree to inform my doctor of my permanent cosmetic enhancement if I require a MRI scan within a <br />3 ronth period of receiving the procedure. <br />I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me <br />by tie practitioner. I understand that infection and possible scarring can occur if I do not adhere to the said <br />n;tructions. <br />To my knowledge I do not have any physical, mental, or medical impairment or disability that might <br />affect my well being as a direct or indirect result of my decision to have the procedure done at this time. I <br />am at least 18 years old. I am not under the influence of drugs or alcohol. <br />For the purpose of documentation, I also consent to the taking of "before" and "after" photographs <br />)t said procedure(s). I give my consent for before and after pictures to be used for marketing. <br />CERTIFY THAT I HAVE READ, AND HAVE HAD EXPLAINED TO ME, AND FULLY UNDERSTAND THE <br />430VE CONSENT FORM AND THAT 1 HAVE REQUESTED TO HAVE PERMANENT COSMETIC EN- <br />-I AMCEMENT <br />N--IAMCEMENT OF MY OWN FREE WILL. <br />hia ie read an understood the above information. <br />Cliart Name Signature <br />4 -ti st Name Signature Date <br />I de�.lare that I give my full consent to the tattooing being carried out by the aforementioned pract tioner. I <br />cordir-n that potential complications, e.g. infection and swelling, for the procedure undertaken, and after - <br />;are instructions have been explained to me. A written aftercare advice sheet containing more detailed <br />nfo,rration has been given to me and I agree that it is my responsibility to read this and follow the instruc- <br />tions on it, until the site has healed. <br />I coif rm that the above information provided by me for this consent form is correct to the best of my <br />knowledge, that I am over the age of consent for this procedure (i.e. 18 years old for tattoos) and that I am <br />not currently under the influence of alcohol or drugs.' <br />S-gnature of Client: Date: <br />Signature of Artist: Date: <br />
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