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U <br /> ° °� Body Art Inspection Report <br /> Date: July 16,2024 <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: AP2400709 <br /> (209)468-3420 <br /> W .sioay.ora/ehd Program <br /> <vF pA?� Element: 4103 <br /> 2. The facility's client consent form and medical questionnaire must include all of the information listed in Form B, and are <br /> available for inspection. Include the following on the tattoo(hardcopy) medical questionnaire and provide a copy to the EHD: <br /> -History of herpes infection at the procedure site. <br /> -History of diabetes. <br /> -History of allergic reactions to latex. <br /> - History of allergic reactions to antibiotics. <br /> - History of hemophilia or other bleeding disorders. <br /> - History of cardiac valve disease. <br /> -Current medications. <br /> -Requirements for antibiotics prior to surgery or dental procedures. <br /> -Other risk factors for blood borne pathogens. <br /> 3. The facility's client consent form and medical questionnaire must include all of the information listed in Form B,and are <br /> available for inspection. Include the following on the tattoo(electronic format)consent form and provide a copy to the EHD: <br /> -Description of procedure. <br /> -Description of what the client should expect following the procedure. <br /> -Notice that inks are not FDA approved and health consequences are unknown. <br /> 4. The facility's client consent form and medical questionnaire must include all of the information listed in Form B, and are <br /> available for inspection. Include the following on the tattoo(hardcopy) medical questionnaire and provide a copy to the EHD: <br /> History of herpes infection at the procedure site. <br /> - History of diabetes. <br /> - History of allergic reactions to latex. <br /> - History of allergic reactions to antibiotics. <br /> -History of hemophilia or other bleeding disorders. <br /> -History of cardiac valve disease. <br /> -Current medications. <br /> -Requirements for antibiotics prior to surgery or dental procedures. <br /> -Other risk factors for blood borne pathogens. <br /> 5. The facility's client consent form and medical questionnaire must include all of the information listed in Form B, and are <br /> available for inspection. Include the following on the permanent cosmetic(electronic format)consent form and provide a copy to <br /> the EHD: <br /> - Description of procedure. <br /> - Notice that inks are not FDA approved and health consequences are unknown. <br /> 6.The facility's client consent form and medical questionnaire must include all of the information listed in Form B, and are <br /> available for inspection. Include the following on the permanent cosmetic(electronic format) medical questionnaire and provide a <br /> copy to the EHD: <br /> - History of herpes infection at the procedure site. <br /> - History of allergic reactions to antibiotics. <br /> - History of hemophilia or other bleeding disorders. <br /> - History of cardiac valve disease. <br /> - Requirements for antibiotics prior to surgery or dental procedures. <br /> -Other risk factors for blood borne pathogens. <br /> 19. HSC 119303, 119308-Appropriate aftercare instructions given to client <br /> OBSERVATIONS: <br /> 1. The tattoo(hardcopy)aftercare instructions did not have all of the elements from Form B. <br /> 2. The permanent cosmetic(electronic format)aftercare instructions did not have all of the elements from Form B. <br /> CORRECTIVE ACTIONS: <br /> 1.At the completion of the procedure, the practitioner shall provide postprocedure instructions that include all elements listed in <br /> Form B. Include the following on the tattoo(hardcopy)aftercare instructions and provide a copy to the EHD: <br /> -Signs and symptoms of infection. <br /> - Indications when to seek medical care. <br /> Reinspection onlabout: A reinspection fee of$172 per hour may be charged. Page 3 of 4 <br /> EH-11/17 <br />