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CONSENT FORM FOR AREOLA REPIGMENTATION (2)

CONSENT FORM FOR AREOLA REPIGMENTATION (2) 2026

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4 out of 5

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The document is a consent form for areola repigmentation, requiring personal information, medical history, and acknowledgment of risks associated with the procedure. It includes sections for allergies, emergency contacts, and a waiver agreement releasing the practitioner from liability. The client must initial various statements regarding the treatment process and aftercare instructions.

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Click ‘Get Form’ to open the CONSENT FORM FOR AREOLA REPIGMENTATION (2) in the editor.
Begin by entering your personal information in the designated fields, including your name, date, address, and contact numbers. This ensures that all necessary details are captured accurately.
Fill in your medical history by listing any allergies and known medical conditions. This section is crucial for ensuring your safety during the procedure.
Indicate any allergies to specific substances such as latex or lidocaine by checking the appropriate boxes. If you have hemophilia, please mark that as well.
In case of an emergency, provide the name and phone number of a contact person who can be reached.
Review the release section carefully. You will need to initial next to each statement confirming your understanding of the procedure and aftercare instructions.
Complete the waiver agreement by filling in the name of the practitioner performing the procedure and signing at the bottom along with the date.

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2010	4 Satisfied (33 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is areola pigmentation treatment?

A: The darker your skin pigment is, the more likely you are to lose some of the /areola pigment. However, the pigment typically returns in full a few months following surgery. In the rare incident that the pigment does not return 100%, you may tattoo the area.

Does areola pigment come back?

Now, lets get into the cost of an areola tattoo. The cost can vary depending on several factors, including the location of the tattoo artist, the complexity of the tattoo design, and the amount of pigment used. On average, an areola tattoo can cost anywhere from $600 to $1,500.

What is areola tattooing for?

If a woman chooses to have areola tattooing, it is the final step of reconstruction after a mastectomy if the was removed as part of the surgery. It involves tattooing a on the skin that may have details that make it look more realistic than a reconstruction might.

What is the CPT code for areola tattooing?

In addition, tattooing of the -areola as part of reconstruction (Current Procedural Terminology [CPT] codes 11920, 11921, 11922) is considered medically necessary and covered when performed by a physician or licensed tattoo artist.

What is areola repigmentation?

Cosmetic tattooing techniques and color pigments are used to create the appearance of an areola. For a unilateral mastectomy patient, this process helps the reconstructed to match the natural . For patients with bilateral reconstruction, both areolas are recreated.

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