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Consent Form Requirements <br /> Health and Safety Code(H&SC) <br /> IZ O-A <br /> ❑ ❑ Client is at least 18 years of age- 119302 (a) <br /> ❑ ❑ Parents/Guardian signature of minor receiving body piercing— 119302(b) <br /> ❑ ❑ S-gnature of client agreeing they have read and completed the consent form— 1193 03 a) <br /> ❑ ❑ Description of procedure— 119303 (a) 1 <br /> ❑ ❑ Description of what the client should expect following the procedure - 199303 (a)2 <br /> ❑ ❑ S-atement regarding permanent nature of procedure— 119303 (a) 3 <br /> ❑ ❑ Notice that inks are not FDA approved and health consequences are unknown— 1193C3 (a)4 <br /> Post-procedure Instructions <br /> H&SC 119303 (a) 5 <br /> La Cu-. <br /> ❑ ❑ hformation of proper care for procedure site— 119303 (a)(5)(A) <br /> n n Restrictions on physical activities— 119303 (a)(5)(B) <br /> n n Signs and symptoms of infection— 119303 (a)(5) (C) <br /> ❑ ❑ Indications when to seek medical care— 119303 (a) (5)(D) <br /> Medical Questionnaire <br /> H&SC 119303 (b) <br /> Li OTA <br /> ❑ ❑ Client status regarding pregnancy- 119303 (b) 1 <br /> ❑ ❑ 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 /> ❑ ❑ History of allergic reactions to antibiotics— 119303 (b)2 <br /> ❑ ❑ 11istory of hemophilia or other bleeding disorders— 119303 (b)2 <br /> ❑ ❑ Ifistory 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 /> ❑ ❑ 0-her risk factors for blood borne pathogens— 119303 (b)4 <br /> V rN m R <br />