Client Information Name: Email Phone: Maintaining Safety and Hygiene Standards STERILIZATION AND INSTRUMENT TRACKING RECORD At Calaveras Barber Shop & SMP, we take safety and hygiene seriously. Our commitment to maintaining high standards ensures the well-being and health of our valued clients. Here’s why safety and cleanliness matter: 1. Client Well-Being: Our rigorous safety protocols are designed to prevent infections, allergic reactions, and other risks associated with SMP procedures. Your health is our top priority. 2. Professionalism and Trust: By prioritizing cleanliness and adhering to strict hygiene practices, we uphold professionalism and build trust with our clients. You can feel confident knowing that your safety is paramount. Record-Keeping Requirements For the specific purpose of SMP procedures, we maintain detailed records, here is what we document: (1) A record of purchase and use for all single-use instruments. (2) A log of all procedures, including the names of the practitioner and client, along with the procedure date. (3) Written proof on company letterhead, confirming the sterilization process for pre-sterilized instruments. This proof clearly identifies the instruments by name or item number and specifies the lot or batch number from the sterilizer run. Supplier Instrument/Needle Lot/ID # Sterilization Date Expiration Invoice Number By signing this consent form, you acknowledge your understanding of our safety practices and agree to comply with our guidelines during your SMP procedure. Practitioner Signature: Clear *By selecting checkmark, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. Date: