MODEL CONSENT APPLICATION Areola Pigmentation and Scar Concealment

MODEL CONSENT APPLICATION Areola Pigmentation and Scar Concealment

This form is for models who are interested in receiving areola tattoos, scar concealment, and or stretch mark revision. We appreciate your time and trust!
Full Name*

First NameLast Name
Date of Birth*
Phone*
Email Address*
example@example.com
Are you pregnant or breastfeeding?*

YesNo
Are you prone to keloids?*

YesNo
Are you diabetic?*

YesNo
Do you have HIV, Hepatitis, or Lupus?*

YesNo
Please list any allergies below, type N/A if you have no known allergies. *
Please upload a photo of the area you wish to be treated (areola, scars, or both) *

Cancelof
Please upload a photo of the area you wish to be treated (areola, scars, or both)

Cancelof
Please upload a photo of the area you wish to be treated (areola, scars, or both)

Cancelof
Which treatment are you interested in?*

Areola and nipple reconstructionScar concealment
Do you plan to receive any laser treatment in the treatment area?*

YesNo
For areola and nipple reconstruction, choose one:*

UnilateralBilateralN/A
When was the last date (month/year) of your reconstructive surgery?*
Choose the following that applies*

Mastectomy (post reconstructive surgery from cancer)Gender ReaffirmingBreast LiftsNo surgery, only areola pigment lossScars from Tummy Tuck/Body Lift/ Cosmetic SurgeryScars from Burns and InjuriesOther
Are you interested in revising your stretch marks, making it less noticeable?*

YesNoMaybe
If interested in stretch marks revision, either with ink or without ink (using a serum) what colors are your stretch marks?
Tell us more about your journey. Share as much as you'd like.
I understand that in exchange for being a model for the purposes of portfolio building and education, I am receiving a session for areola, scar concealment, and or stretch mark revision. I agree to cover the cost of supplies which we will agree on prior to officially booking. I understand that no profit is made during this session, therefore, I agree and I understand the taking of photographs and/or video of the procedure is required and may be used for training, teaching, and media examples of the procedural process. I agree to allow photos and videos to be used as training and as an example of the procedure and process to prospective patients. I understand I will be given no financial compensation for the use of these images. Signature
blanksblank
I agree to visit the studio or send high-quality images of my healed results in natural lighting. If my artist requests in-person photos for their case study, I may visit the studio. My face won’t be shown, and tattoos can be covered or blurred for privacy.
Signature
blanksblank
I, First Name Last Name am over the age of 18, am not under the influence of drugs or alcohol, and consent to be a model for Boston Medical Tattoo. Following the purpose of portfolio building and finetuning our skills in the areola repigmentation tattoo, and or scar camouflaging session. Signature
I understand this is a cosmetic tattoo procedure and it carries with it possible complications and consequences associated with this type of procedure, including, but not limited to, infection, allergic reaction, scarring, inconsistent color and spreading, fanning, or fading of pigments. 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 tattoo process and therefore not a science but an art. I request the cosmetic tattoo procedure and accept the permanence of the procedure as well as the possible complications and consequences of the said procedure. Signature
blanksblank
Model Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Thank you for taking the time to complete this form. Once submitted, our team will review your information and follow up with a decision regarding your appointment. We appreciate your patience and look forward to assisting you.
Should be Empty: