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Body Art Inspection Report Date: 8-30-2023 <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: SR0087097 <br /> (209)468-3420 <br /> O• �P' www.sioov.org/ehd Program <br /> gc�FOR?' Element: 4103 <br /> PR Number PRACTITIONERIARTIST NAME PR Number PRACTITIONERIARTIST NAME <br /> Courtney Conley exp Aril 6,2024 Above Trainin .com <br /> Observations and Corrective Actions: <br /> 18. The facilities client consent form and medical questionnaire must include all of the information listed in Form B, <br /> and are available for inspection. HSC 119303 <br /> OBSERVATIONS: Medical Questionnaire lacks these statements <br /> Herpes at the procedure site <br /> History of reactions to antibiotics <br /> Current medications <br /> Requirements for antibiotics prior to surgery or dental procedures <br /> History of cardiac vale disease <br /> CORRECTIVE ACTIONS: Provide these statements on medical consent form. <br /> Notes: <br /> 1. Facility performs stretch mark camouflage tattoos. <br /> 2. 1 observed sterilization certificates for Cheyenne needles 2023-19-022 <br /> 3. Caviwipes are used 3 minute kill time. <br /> 4. Sharps Assure Mail back <br /> 323A Fairfield Road Unit 6 <br /> Freehold, NJ 07 <br /> 5. Report emailed to ccregenesis@gmail.com <br /> 6. 1 received corrections-updated forms (medical questionnaire ) via email on 8/30/2023 <br /> Reinspection on/about: A inspection fee of$162 per hour may be charged. Page 2 of 2 <br /> EH-11/17 <br />