Laserfiche WebLink
Consent Form Requirements <br /> Health and Safety Code(H&SC) <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'orm— 119303 (a) <br /> Description of procedure— 119303 (a) 1 <br /> Description of what the client shpuld expect following the procedure- l 19303 (a)2 <br /> Statement regarding perman'Tt✓nature of procedure— 119303 (a)3 <br /> Notice that inks are not FDA approved and health consequences are unknown— 119303 (a)4 <br /> Post-procedure Instructions <br /> H&SC 119303 (a) 5 <br /> In Out j <br /> Information of proper care for rocedure site— 119303 (a)(5)(A) <br /> Restrictions on physical 6tivities— 119303 (a)(5)(B) <br /> Signs and symptoms ofinf ction— 119303 (a)(5)(C) <br /> Indications when to seek edical care— 119303 (a)(5)(D) <br /> Medical Questionnaire <br /> I H&SC 119303 (b) <br /> In Out I <br /> Client status regarding pregnancy- 119303 (b) 1 <br /> History of herpes infection at the procedure site— 119303 (b)2 <br /> History of diZr`gic <br /> btes— 119303 (b)2 <br /> Historyotergicreactionsto <br /> reactions to latex— 119303 (b)2 <br /> History oantibiotics— 119303 (b)2 <br /> Historyof emoph�'ia or other bleeding disorders— 119303 (b)2 <br /> History 7edicaVns <br /> Fardiac valve disease 119303 (b)2 <br /> Current — 119303 (b)3 <br /> Requirements for antibiotics prior to surgery or dental procedures— 119303 (b)3 <br /> Other risk factor�'for blood borne pathogens— 119303 (b)4 <br /> COWIDI=NTIAL <br /> Form B <br />