ࡱ > bjbjdd 4 cc x 8 $ C _ F 8 : : : : : : $ o %! l ^ ^ s R 8 8 F_ F $ 0 ! ! ! ^ ^ ! : DEPARTMENT OF HEALTH AND HUMAN SERVICES INFECTED CLIENT REPORT FORM FORMCHECKBOX Body Piercing FORMCHECKBOX Electrology FORMCHECKBOX Micropigmentation FORMCHECKBOX Tattooing The owner or operator of the establishment shall report all infections resulting from the practice of tattooing, body piercing, electrology or micropigmentation which the practitioner knows to the Department within twenty-four (24) hours. Please provide the following information: The infected client shall be referred to a physician. Has the client been referred? Yes / No Name of the establishment: _____________________________________________________________ Location of the establishment: ___________________________________________________________ Name of the establishment owner/operator: _________________________________________________ Establishment telephone #: ___________________ Date procedure performed: ____________________ Name of the individual who performed the procedure: ________________________________________ Is the individual who performed the procedure licensed? Yes / No License #: ____________________ Client name: ____________________________ Client Phone #(s): _____________________________ Establishment owner operator remarks: ____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Individual who performed procedure remarks: ______________________________________________ ________________________________________________________________________________________________________________________________________________________________________ (Please put additional notes/remarks on the back of this form or attached sheet) Send: * this completed form * copy of aftercare instructions (signed by client if applicable) * copy of clients permanent record To: Lisa Silva: HYPERLINK "mailto:lisa.silva@maine.gov" lisa.silva@maine.gov Department of Health & Human Services Division of Environmental Health 11 State House Station Augusta ME 04333 Tel. (207) 287-5671 Health Inspection Program Fax (207) 287-3165 HHE-615 Revised 12-29-17 D E M N \ ] ^ n u v / 0 ҮҦҔҦ҂|sg\T h CJ aJ h hY+ CJ aJ hY+ hY+ 5CJ aJ hK 5CJ aJ hK CJ #j\ hY+ hY+ CJ UaJ #j hY+ hY+ CJ UaJ hY+ CJ aJ #jt hY+ hY+ CJ UaJ #j hY+ hY+ CJ UaJ hY+ hY+ CJ aJ j hY+ hY+ CJ UaJ hy CJ aJ h|Z CJ aJ h|Z ( D E ] m ( G A vdh &d P ^vgd|Z $ vdh ^va$ gd|Z vdh ^vgd|Z v^vgd|Z dh gdY+ gd|Z 0 1 ; B I f l ! ' ` a x } " ( : A } 9 ? F A h*xn hY+ h CJ aJ hfa CJ aJ ha CJ aJ hY+ CJ aJ h*xn CJ aJ h CJ aJ hY+ hY+ CJ aJ KA G H I c h i + , - ´´}y}y}y}yh j h(+^ hwQ UmH nH u h@ j h@ Uh3 h3 5CJ aJ hY+ hY+ 5CJ aJ hY+ 5CJ aJ hn h3 0J 5CJ aJ j h3 5CJ UaJ h3 5CJ aJ h($ 5CJ aJ hK 5CJ aJ h CJ aJ hK CJ aJ hY+ CJ aJ hY+ hY+ CJ aJ $ - S u n^ngd|Z 5$ 7$ 8$ 9D H$ gd|Z !5$ 7$ 8$ 9D H$ gd|Z dh `gd3 dh `gdY+ dh ^`gd3 vdh ^vgd|Z h3 h3 5CJ aJ h@ h{i' htMT h hP[v h= h%0 h|Z OJ QJ ^J h|Z h|Z OJ QJ ^J h|Z h|Z OJ QJ ^J dh `gd3 2 1h:p|Z / =!"#$% t D e C h e c k 2 t D e C h e c k 2 t D e C h e c k 2 t D e C h e c k 2 D d - z H A 2 ? M C D C A u g u s t a 2 8 6 W a t e r C o l o r P i c t u r e 1 M : \ L E T T E R H E A D - L O G O S - O c t o b e r 2 0 1 7 - R i c k e r H a m i l t o n \ S t e p 2 - J P E G F i l e s \ M C D C A u g u s t a 2 8 6 W a t e r C o l o r . j p g " R ٞ 5Q0^R( {F 5Q0^R(DExif MM * b j( 1 " r2 i - ' - 'Adobe Photoshop CC 2017 (Windows) 2017:11:13 14:32:30 ` w " *( 2 H H Adobe_CM Adobe d " ? 3 !1AQa"q2B#$Rb34rC%Scs5&DTdE£t6UeuF'Vfv7GWgw 5 !1AQaq"2B#R3$brCScs4%&5DTdEU6teuFVfv'7GWgw ? w{dt^?G+]nǶݹ}e!_syk=sh7[]_ZFKYK t }ge+:66jeYY`{ko{m)f> [g~K' cLI& h=FR?/DnnnkȠSͣ7zo ,GMߟvQY :n~SO /S,tw1,2ٲGQc0ߤ6=\ԫ&\>x !aVI$Zl&ݪ˾=Ɯ7 -] mZ2IY8_XF0:ΛWkw N6)ki,hS^{5-mMi宀 Tˁ'{X .ŭHS 9cׂjZ}'ٷrٓL;_I$I$S]{,s 69'=swAÆ=*sdGcL]Ϸ uڸ%8ӹբ+a .4\y569z h훜h˵.U2gvV_Y}ݮ!)$#sI jw~wܥM:PG7f浵vKtб-jx1ko\#zJg'`>nZָmM{_[=$Yc ݓc;{\_+ /kpZ߫o|ϩY.ɲql]cݒ~ ![oԏOAoӡ;5KJ~Jٯ?q/sq{tPwՏ;]v+K}c}o}5i&z|ϪZ$1ApmbDm GKG_~;\ J9>*ݶ5%]#G.~8|BI($I)J/s;c!TIM