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Us parental consent forms DRIVER'S EDGE PARENTAL CONSENT WAIVER, RELEASE AND INDEMNITY AGREEMENT PLEASE READ THIS AGREEMENT CAREFULLY I understand that Driver's Edge will conduct a behind-the-wheel and classroom driver education

Printable hepatitis b vaccinat... Hepatitis B Vaccine Consent/Declination Form EMPLOYEE NAME: PLEASE PRINT I have been informed of the symptoms and modes of transmission of blood borne pathogens including hepatitis B virus (HBV).

Hemodialysis procedural consen... HH FORMS 571514 R03/11 Printed by the Digital Print Center HH. Page 1 of 2 . *6816*. 6816. INFORMED CONSENT FOR HEMODIALYSIS ...

Sample of parental consent for... North Carolina Youth Soccer Association Medical Consent / Waiver of Liability and Release (to be given to local Association) 20 - 20 NCYSA Policy # Excess policy to any valid and collectible insurance.

Medication consent form cambri... SG/LG/SAMedicationConsent20100122. Commonwealth of Massachusetts. Department of Early Education and Care. MEDICATION CONSENT FORM 606 CMR ...

Consent form pm 330 State of California Health and Human Services Agency California Department of Public Health STERILIZATION CONSENT FORM NON-FEDERALLY FUNDED NOTICE YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. CONSENT TO STERILIZATION STATEMENT OF PERSON OBTAINING CONSENT I have asked for and received information about sterilization from Bef...

Boise school district physical... Occupation: Date of last physical exam: / /. Do you currently take any prescription medications? yes no. If yes, please list: Do you take vitamins, laxatives, ...

Sterilization consent form lou... Form Approved: OMB No. 0937-0166 Expiration date: 12/31/2012 CONSENT FOR STERILIZATION NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY

Consent permanent form CONSENT TO APPLICATION OF PERMANENT MAKEUP PROCEDURE DATE NAME ADDRESS HOME/CELL PH. DOB CITY WORK PH. I request the permanent skin pigmentation procedure s and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure s. X There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. I consent initial or waive initial the patch test. I medication for depression or any other mood altering prescription I will advise my technician. If I have ever had cold sores I will consult with and strictly follow my doctor s instructions before contemplating any permanent cosmetic procedure around my lips. X such procedure s. I certify I have read and initialed the above paragraphs and have had explained to my understanding this consent and procedure permit. X There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction. I consent initial or waive initial the patch test. If waived I release the technician from liability if I develop an allergic reaction to the pigment. I understand that if I have any skin treatments laser hair removal plastic surgery or other skin altering procedures it may result in adverse changes to my permanent cosmetics. STATE ZIP EMAIL am over the age of 18 am not under the influence of drugs or alcohol am I not pregnant or nursing and desire to receive the indicated permanent cosmetic procedure. The general nature of cosmetic tattooing as well as the specific procedure to be performed has been explained to me. PROCEDURE s NO. OF VISITS REQUIRED COST OF PROCEDURE s I have been informed of the nature risks and possible complications and consequences of permanent skin pigmentation* I understand the permanent skin pigmentation procedure carries with it known and unknown complications and consequences associated with this type of cosmetic procedure including but not limited to infection scarring inconsistent color and spreading fanning or fading of pigments. Corneal abrasions are a rare side effect especially if I rub or scratch my eyes or apply contacts too soon after any eyeliner procedure. I understand the actual color of the pigment may be modified slightly due to the tone and color of my skin* I fully understand this is a tattoo process and therefore not an exact science but an art. I request the permanent skin pigmentation procedure s and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure s. X There is a possibility of an allergic reaction to pigments. A patch test is advisable however it does not ensure a client will not have an allergic reaction* I consent initial or waive initial the patch test. If waived I release the technician from liability if I develop an allergic reaction to the pigment. I understand that if I have any skin treatments laser hair removal plastic surgery or other skin altering procedures it may result in adverse changes to my permanent cosmetics.

Registration emergency consent... REGISTRATION / EMERGENCY / CONSENT FORM Child's Name: Address: Mother's Name: Name of Work Place: Father's Name: Name of Work Place: Mother may pick up child: Preferred Email Address: Child's Dentist:

Georgia department of correcti... SOPIVOO3-0012 Attachment 1 Revised 5/15/03 GEORGIA DEPARTMENT OF CORRECTIONS CRIMINAL/DRIVER mSTORY CONSENT FORM I hereby authorize the Georgia Department of Corrections to receive all criminal history

Tdap consent form Tetanus Diphtheria and Pertussis Vaccine Tdap Vaccine Consent Form Tetanus is an acute often fatal disease caused by an extremely potent neurotoxin. The toxin causes neuromuscular dysfunction with rigidity and spasms of skeletal muscles. The vaccine is administered in the deltoid only. Tdap may be given during pregnancy with a note of consent from OB-GYN only. The muscle spasms usually involve the jaw lockjaw and neck and then become generalized* Tetanus leads to death in up to 2 cases out of 10. Diphtheria may cause both localized and generalized disease. It causes a thick covering in the back of the throat and can lead to breathing problems paralysis heart failure and even death. Pertussis Whooping Cough is a disease of the respiratory tract most of caused by B-pertussis. It causes severe coughing spells pneumonia vomiting and disturbed sleep* Tdap vaccine is recommended for adolescents and adults 11-64 years old. A. PATIENT INFORMATION Please Print Last Name - Name as it appears on insurance card if applicable Date of Birth MM/DD/YYYY Age First Name Male MI Female Street Address Apt or Unit City State Zip Code Phone Number B. PAYMENT ARRANGEMENTS Please Bill Insurance. Health Insurance Plan Name e*g* Aetna Premera Regence Group Health etc* Member Insurance ID Number Employer Paid Other Please Describe Employer Name Primary Care Physician Please print City Why is this information needed Various insurance plans require that we notify your primary care physician that you have received certain immunizations so that your medical record can be updated* C. ACKNOWLEDGEMENT and AUTHORIZATION YES NO Are you allergic to preservatives neomycin thimerosal or latex Do you have a history of Guillain-Barre syndrome or an active neurological disorder Have you ever had a serious reaction after receiving any vaccination Do you have a fever diarrhea or vomiting today For Women Are you pregnant or suspect you are pregnant If yes you must consult your physician* Check with your physician and/or your healthcare provider before receiving this vaccine if you checked yes on any of the above questions. Participants who should not take the vaccine Anyone who has had a life-threatening allergic reaction after a dose of DTP DTap DT or Td should not get Tdap* Anyone who had a coma or long or multiple seizures within 7 days after a dose of DTP or DTaP should not get Tdap unless a cause other than the vaccine was found. Talk with your provider if the person getting the vaccine has epilepsy or another nervous system problem had severe swelling or severe pain after a previous dose of DTP DTaP DT Td or Tdap vaccine or has had Guillain Barre Syndrome. vaccine. A person with a mild illness or low fever can usually be vaccinated* Possible side effects from the vaccine Most people have no side effects from Tdap vaccines. Injections are given by injection into a muscle of the upper arm* This may cause soreness for a day or two mild fever headache tiredness nausea vomiting diarrhea stomach ache chills body aches sore joints rash swollen glands.

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