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t <br /> Consent Form Requirements <br /> Health and Safety Code <br /> In Out <br /> LA- ❑ Client is at least 18 years of age- 119302 (a) <br /> ❑ ❑l k Parents/Guardian signature of minor receiving body piercing- 119302 (b) <br /> G ❑ Signature of client agreeing they have read and completed the consent form- 119303 (a) <br /> ❑ Description of procedure- 119303 (a) 1 <br /> C6- ❑ Description of what the client should expect following the procedure- 199303 (a)2 <br /> (X ❑ Statement regarding permanent nature of procedure- 119303 (a)3 <br /> ❑ Post ocedure instructions- 119303 (a)4 <br /> a�r <br /> information of proper care for procedure site <br /> restrictions on physical activities <br /> c) signs and symptoms of infection <br /> d) indications when to seek medical care <br /> Medical Questionnaire <br /> H&SC 119303 (b) <br /> In Out <br /> ❑ Client status regarding pregnancy- 119303 (b) 1 <br /> ❑ 0- History of herpes infection at the procedure site- 119303 (b)2 <br /> ,,A- ❑ 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- 119303 (b)2 <br /> ❑ ,O- History of cardiac valve disease 119303 (b)2 <br /> ❑ t�-- Current medications- 119303 (b)3 <br /> ❑ t-4-- 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 />