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Consent Form Requirements <br /> Health and Safety Code <br /> In Out <br /> ❑ Client is at least 18 years of age- 119302(a) <br /> ❑ Parents/Guardian signature of minor receiving body piercing— 119302(b) <br /> ❑ Signature of client agreeing they have read and completed the consent form— 1193 03 (a) <br /> ❑ Description of procedure— 119303 (a) 1 <br /> CK ❑ Description of what the client should expect following the procedure- 199303 (a)2 <br /> ❑ Statement regarding pennanent nature of procedure— 119303 (a)3 <br /> ❑ Post procedure instructions— 119303 (a)4 <br /> information of proper care for procedure site <br /> restrictions on physical activities <br /> signs and symptoms of infection <br /> d indications when to seek medical care <br /> Medical Questionnaire <br /> H&SC 119303 (b) <br /> Tii Out <br /> ❑ Client status regarding pregnancy- 119303 (b) 1 <br /> "�� ❑ History of herpes infection at the procedure site— 119303 (b)2 <br /> �) ❑ History of diabetes— 1193 03 (b)2 <br /> ❑ History of allergic reactions to latex— 1193 03 (b)2 <br /> tO ❑ History of allergic reactions to antibiotics— 119303 (b)2 <br /> IPA fi< ❑ History of hemophilia or other bleeding disorders—1193 03 (b)2 <br /> �R ❑ History of cardiac valve disease 119303 (b)2 <br /> +law} <br /> tittU,az jV Current medications— 119303 (b)3 <br /> tusv R ❑ Requirements for antibiotics prior to surgery or dental procedures— 1193 03 (b)3 <br /> to Indli ❑ Other risk factors for blood borne pathogens— 119303 (b)4 <br /> Form B <br />