Areola Model Form

MODEL CONSENT APPLICATION 3D Areola Tattooing

This form is for models who are interested in receiving areola tattoos. Not all applicants will be selected. We appreciate your time and trust!
In order to help me streamline the booking process please fill out any relevent information I may need for your appointment below. If a question does not apply to you use "N/A" in the provided space. If there is a question you do not understand or are not sure how to answer, give a best guess and let me know at the end how I can help.
Name

First NameLast Name
Birth Date*

MonthDayYear
MM/DD/YYYY
Phone Number*
Please enter a valid phone number.
Email Address*
(example@example.com)
Are you pregnant or breastfeeding?*

YesNo
Are you prone to Keloids?*

YesNo
Are you diabetic?*

YesNo
Do you have AIDS, Herpes, HIV, or Lupus*

YesNo
Please list any allergies below, type N/A if you have no known allergies:*
Please list any medications or supplements you take, type N/A if you do not take any:*
If there is a cover-up involved, please take a well-lit photo of the previous tattoo that you would like covered. Also please note how old the tattoo is in the description box.*
Please upload a photo of left breast: *

Cancelof
Please upload a photo of right breast:*

Cancelof
Please upload a photo of both breast (front view):*

Cancelof
When was the last date (month/year) of your reconstructive surgery?*
For areola and nipple reconstruction please choose one ?*

UnilateralBi-lateralCover-up of old reconstructionN/A
Do you plan to have any laser treatments in the area to be tattooed?*

YesNo
Which service are you interested in today?*

New Areola TattooCover-up of Previous Areola Tattoo
Choose the following that applies to you:*

Mastectomy (post reconstructive surgery after cancer or positive genetic test)Breast LiftsNo surgery, only areola pigment lossOther
If you are requesting a cover-up when was the last time you had areola tattooing? (if you are not requesting areola cover-up put N/A)*
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 free session for areola reconstruction. 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 will 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 as well as in the promotion of the service whether on social media, website or any other public means. I understand I will be given no financial compensation for the use of these images.
Initial Initial*
Participation in our Free Areola Restoration Clinic is a heartfelt opportunity to receive this life-changing service at no cost. In return, all clients who take part in the clinic grant BeYOUtiful Ink Studio permission to use photos, videos, and interviews for educational and promotional purposes.

All media will be captured and shared with the utmost respect and discretion. While some content may include faces or identifying features, nothing will be used in a way that feels exploitative or unkind. Our intention is always to honor your story, celebrate your healing, and help others understand the beauty of this work.

By participating, you acknowledge and agree to this policy. If you have specific boundaries you’d like us to respect, please let us know — your comfort and trust are always our priority.
Initial Initial*
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.
Initial Initial*
I am over the age of 18, am not under the influence of drugs or alcohol, and consent to be a model for BeYOUtiful Ink Cosmetic and Medical Tattooing. Following the purpose of portfolio building and finetuning our skills in the areola repigmentation tattoo.
Initial Initial*
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.
initial Initial*
Any additional questions? Place your questions here.
Signature*

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Date*

MonthDayYear
MM-DD-YYYY
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.
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MODEL CONSENT APPLICATION 3D Areola Tattooing