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Page 1 of 2 <br /> Alfonso Arambula [EH] <br /> From: Alfonso Arambula [EH] <br /> Sent: Monday, January 07, 2013 10:20 AM <br /> To: 'Oc Thomas' <br /> Subject: RE: Pins& Needles tattoo waiver and aftercare <br /> Attachments: FormChecklist.pdf; IPCP-8-2-12.doc <br /> Good Morning OC, <br /> reviewed the Consent Form and After Care instructions I received from you. Currently both forms lack <br /> information and need to include required information stated in AB300 section 119303(a)(b). I included a <br /> checklist showing the information needed to be included in the consent form and after care instructions. <br /> All boxes checked OUT indicate missing information. Please update the consent form and aftercare <br /> instructions and email the forms for review. Below I listed the items missing and the wording required on <br /> your forms. <br /> 119303(a) Consent Form <br /> (1) A description of the Procedure <br /> 119303 (b) Consent Form—Medical Questionnaire <br /> (2) If your client has a history of herpes infection at the procedure site, <br /> (2) If your client has a history of allergic reactions to latex or antibiotics <br /> (2) If your client has a history of cardiac valve disease <br /> (3) Whether your client has a history of medication use or is currently using medication, including <br /> prescribed antibiotics prior to dental or surgical procedures <br /> (4) If client has other risk factors for bloodborne pathogen exposure, i.e. HIV, Hep C <br /> 119303 (a)(4)AfterCare Instructions <br /> (C) Signs and symptoms of infection, including, but not limited to, redness, swelling, tenderness <br /> of the procedure site, red streaks going from the procedure site towards the heart, elevated body <br /> temperature, or purulent drainage from the procedure site. <br /> (D) Signs and symptoms that indicate the need to seek medical care. <br /> As well if you could please submit the Infection Prevention and Control Plan. The plan was required to be <br /> submitted December 03, 2012 as stated on the November 02, 2012 inspection. Without the plan Pins <br /> and Needles is out of compliance. I attached a template Infection Prevention and Control Plan to help <br /> assist your facility in developing the plan. <br /> If you have any questions feel free to call or email me. <br /> Thank you, <br /> Alfonso Arambula, Sr REHS <br /> San Joaquin County <br /> Environmental Health Department <br /> 1868 E. Hazelton Ave Stockton, CA 95205 <br /> Email: aarambulaCa)sjcehd.com (209)468-9673 <br /> EHD Website: http://www.sogov.org/ehd Fax(209)468-8392 <br /> From: Oc Thomas [mailto:ocnebu@gmail.com] <br /> Sent: Friday, December 28, 2012 6:09 AM <br /> To: Alfonso Arambula [EH] <br /> Subject: Re: Pins &Needles tattoo waiver and aftercare <br /> Hey Alfonso sorry for the late response I'm just getting back from Washington. I will <br /> send that to you ASAP. <br /> 1/7/2013 <br />