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COMPLIANCE INFO
Environmental Health - Public
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EHD Program Facility Records by Street Name
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4100 – Safe Body Art
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PR0545109
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COMPLIANCE INFO
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Entry Properties
Last modified
3/5/2025 12:14:23 PM
Creation date
3/18/2021 10:57:02 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0545109
PE
4110 - BODY ART PRACTITIONER REGISTRATION
FACILITY_ID
FA0025657
FACILITY_NAME
FLOW YOGA WELLNESS (AGUIRRE, CRYSTAL)
STREET_NUMBER
145
Direction
W
STREET_NAME
TENTH
STREET_TYPE
ST
City
TRACY
Zip
95376
CURRENT_STATUS
Active, billable
QC Status
Approved
Scanner
SJGOV\cfield
Supplemental fields
Site Address
145 200 W TENTH ST TRACY 95376
Suite #
200
Tags
EHD - Public
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I have been told that allergic reactions to pigment are very rare,however,they can occur and <br /> when they do occur they can be serious and especially difficult to treat. <br /> I understand the markings are permanent and that there is a possibility of hyper pigmentation <br /> resulting from a procedure,especially in individuals prone to hyper pigmentation from a scar or other <br /> injury. <br /> I have been told that a follow up procedure may be required. <br /> I understand that any further touch ups needed will not be covered and additional cost may <br /> occur. <br /> Other risks involved with the procedure may include,but not limited to: infections,allergic and <br /> other reaction(s) to applied pigments,allergic and other reaction(s) to products applied during and after <br /> the procedure,fanning or spreading of pigment (pigment migration),fading of color and other unknown <br /> risks. <br /> I accept full responsibility for any and all,present and future, medical treatment(s) and <br /> expenses I may incur in the event I need to seek treatment(s) for any known or unknown reason <br /> associated with the procedure planned for me. <br /> I have been given the opportunity to ask questions about the procedures and the procedure to <br /> be used and the risks and hazards involved and I believe that I have sufficient information to give this <br /> informed consent. <br /> I have agreed that if I should have a complaint of any kind whatsoever, I shall immediately notify <br /> Crystal Aguirre DBA Microblade Aesthetics/Brows by Crystal and I further agree that any <br /> controversy or claim arising out of relating to this consent and/or any signed contract between myself <br /> and the Practitioner or the breach thereof,shall be settled by arbitration in the state of California in <br /> accordance with he Rules of the American Arbitration Association and judgment of the award rendered <br /> by the arbitrator(s) may have entered in any court having jurisdiction thereof. <br /> I understand that if I have an infection,adverse reaction,or allergic reaction to the procedure, I <br /> must notify Crystal Aguirre DBA Microblade Aesthetics/Brows by Crystal and my health care <br /> practitioner. <br /> I certify this form has been fully explained to me and I have read it or it has been read to me. I <br /> understand its contents. <br /> I have received a copy of the Post Procedure Instructions. It has ben fully explained to me and I <br /> have read it or it has been read to me. I understand its contents. <br /> Signature Date <br />
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