Laserfiche WebLink
Consent Form Requirements <br /> Health and Safety Code(H&SC) <br /> Out <br /> ❑ Client is at least 18 years of age- 119302(a) <br /> s <br /> Parents/Guardian signature of minor receiving body piercing— 1193 02(b) <br /> ❑ Signature of client agreeing they have read and completed the consent form— 119303 (a) <br /> ❑ Description of procedure— 1193 03 (a) 1 <br /> ❑ Description of what the client should expect following the procedure- 199303(a)2 <br /> ❑ Statement regarding permanent nature of procedure— 1193 03 (a)3 <br /> ❑ Notice that inks are not FDA approved and health consequences are unknown— 119303 (a)4 <br /> Post-procedure Instructions <br /> H&SC 119303 (a)5 <br /> In Out <br /> CK, ❑ Information of proper care for procedure site— 1193 03 (a)(5)(A) <br /> CK ❑ Restrictions on physical activities— 119303 (a)(5)(B) <br /> ❑ 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 /> In Out <br /> ❑ ❑ Client status regarding pregnancy- 119303 (b) 1 <br /> ❑ ❑ History of herpes infection at the procedure site— 1193 03 (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 /> ❑ ❑ History of hemophilia or other bleeding disorders—1193 03 (b)2 <br /> ❑ ❑ History 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 />