Areola Tattoo Consent Form

Areola Tattoo Consent Form

Malorie Harris LLC
Client Information
Name

First NameLast Name
Age
Birth Date

MonthDayYear
Date
Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?

YesNo
FEMALE ONLY: Are you pregnant or nursing?

YesNo
Do you have a communicable disease?

YesNo
Do you have any skin conditions?

YesNo
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Please tell about your medical history (e.g. DIABETES, CARDIOVASCULAR DISEASE, EPILEPSY, BLOOD RELATED DISEASE, ALLERGIES, KELOID SCARS, DIABETES, COLD SORES, IRON DEFICIENCY, ANEMIA, HEMOPHILIA, HYPOGLYCEMIA, HEART PROBLEM, AIDS (HIV), HEPATITIS, CANCER, HIGH BLOOD PRESSURE, ACCUTANE, BLOOD THINNER, SKIN DISORDER/S, MENOPAUSE, PACEMAKER, BOTOX, PRONE TO FAINTING, FILLERS, MRI IN THE NEAR FUTURE? CURRENT MEDICATION?
If yes, please identify the condition.
Acknowledgment and Waiver
By checking the box, I am in agreement with the following:

I understand that this procedure is a permanent change to my skin and body.
By checking the box, I am in agreement with the following:

I understand that I must be over the age of 18 and cannot be under the influence of drugs or alcohol during the procedure.
By checking the box, I am in agreement with the following:

I understand that I may not be a candidate for an Areola/Nipple Tattoo if any of the following pertains to me: Radiation treatments damaged my breast skin/ My breast skin became overly thinned when tissue was removed during the mastectomy/ I have lymphedema that involves the chest/ I have a history of infections in the breast area.
By checking the box, I am in agreement with the following:

I understand that I must be 6-9 (9 if a nipple mound was created) months post reconstruction surgery, completely healed, with no current chemo or radiation treatments.
By checking the box, I am in agreement with the following:

I have been informed of the risks, and possible complications resulting from 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: slight discomfort associated with procedure, infection, and scarring, inconsistent color, spreading, fanning or fading of pigments, slight bleeding & bruising. I understand the actual color of the pigment may be modified slightly, due to the undertone and color of my skin. I fully understand this is a tattoo process and therefore not an exact science, but an art. Malorie Harris LLC makes no attempt to, or claim to, practice medicine.
By checking the box, I am in agreement with the following:

I have received post procedure instructions (located at the bottom of this page) and I will strictly adhere to such instructions. I understand that my failure to do so may jeopardize my chances for a successful procedure and can result in infection.
By checking the box, I am in agreement with the following:

Should I have diabetes, epilepsy, haemophilia, a heart condition, or any other medical or skin condition that can interfere with the application or healing of my Areola/Nipple Tattoo, I must reveal that information to my technician. I understand I must contact my doctor and bring a letter stating that it is safe to have my procedure performed if I have any said condition.
By checking the box, I am in agreement with the following:

I am not the recipient from an organ or bone marrow transplant, or if I am, I have taken the prescribed regimen of antibiotics that is required by my doctor in advance of any invasive procedure such as tattooing.
By checking the box, I am in agreement with the following:

Allergic reactions to pigment is always a possibility. A patch test is possible however it does not ensure a client will not have an allergic reaction. I release the technician from liability should I develop an allergic reaction to the pigment.
By checking the box, I am in agreement with the following:

I recognize that it is not possible to determine if or whether I might have any allergic reaction to any of the numbing agents used in the procedure; I understand and accept the risk that such a reaction is possible.
By checking the box, I am in agreement with the following:

I understand that complications are possible when receiving the Areola/Nipple procedure, particularly in the event that post-procedural instructions are not followed.
By checking the box, I am in agreement with the following:

I understand that Areola/Nipple tattooing is an art form and NOT an exact science, and I acknowledge that no guarantees have been made to me as to the result of this procedure. I understand that some skin types will not accept or heal pigment in a consistent manner. Skin is unique and Malorie Harris LLC cannot in any way predict how my skin may react to the procedure or how it may or may not accept color.
By checking the box, I am in agreement with the following:

I understand that this is a tattoo and with time, pigments can and will fade or change according to metabolism, lifestyle, skin type, medications, age, smoking, alcohol, sun exposure, creams and lotions.
By checking the box, I am in agreement with the following:

I accept full responsibility for determining the color, shape and position of the pigments that will be applied. I understand that the actual healed color of the pigment will be modified to an extent due to my own unique undertones.
By checking the box, I am in agreement with the following:

I allow my tattoo to be photographed and used for Malorie Harris LLC's portfolio (No areas above shoulders/neck or below waist will be shown). Thank you for allowing your medical tattoos to be displayed as it helps bring awareness to this restorative and healing art.I do not want my photos to be used for portfolio purposes but I understand that for insurance purposes, a before and after picture must be taken and kept in confidential client records.
By checking the box, I am in agreement with the following:

I indemnify and hold harmless Malorie Harris LLC against any claims, expenses, damages, and liabilities.
By checking the box, I am in agreement with the following:

I confirm that the information I provided in this document is accurate and trueI acknowledge by signing this consent form, I have been given the full opportunity to ask any and all questions about Areola/Nipple Tattooing, its process, and the risk involved from Malorie Harris LLC. The decision to have Areola/Nipple Tattooing performed is my own and I understand and accept all risk involved, therefore releasing Malorie Harris LLC from any liability. Areola/Nipple Tattooing is not a medical procedure, but an art form, the art of tattooing. .
Signed Date

MonthDayYear
Date
Client Signature

Clear
Areola/ Nipple Tattoo Aftercare

A transparent film dressing will be placed on your tattoo(s) unless allergy is present.
Do not remove for 7 days and shower with film on.
Do not submerge in water (bath, pool, ocean, hot tub, etc) for 14 days.
Do not work out or sweat for 5 days.

On day 7, remove transparent film dressing and get in shower. Wash with gentle soap (Dial, Dove, Cetaphil), water and finger tips.
After shower, sit topless and air dry for 1 hour.
Once dry, text Malorie, 314-265-7542, and she will determine if you need a touch-up at six weeks.
If you do not wish to send a photo, your doctor can determine if you need a touch-up at your next appointment.
If not using a transparent film dressing, aquaphor will be applied immediately following procedure along with a non stick gauze pad, you will need to apply aquaphor 3 times a day for 3 days and change the gauze pads.
Should be Empty: