Final Mile Ink

Patient Portrait

Your Privacey is protected at cathi.ink corp dba Final Mile Ink

The only person receiving and viewing this form is Areonip Architect Cathi Locati. Information you provide is never shared with anyone, ever. Upon submission of this form, a HIPPA protected file is created for you at Final MIle Ink and maintained throughout your Micropigmentation process. Thank you for your trust. Required fields must be filled in to create the best picture of you for your consultation with Cathi.

Your name*

First and last name you use with your current Health Insurance Co.

Which state do you live in (U.S.)?

Please indicate the country, region or area in which you live if outside of the United States.

Are you a female breast cancer survivor?*

yes

Are you a male breast cancer survivor?

yes

How many years cancer free?

If you're not a breast cancer survivor please explain the services you seek...

Who may we thank for referring you to us?

Who referred you?

What words did you use in your internet search?

Please help Final Mile Ink know which keywords to list so that others can find us too!

Today's date*

Date of Birth*

Month, day and year you were born

Your current age*

How old are you now?

What is your ethnicity / nationality?*

Select or enter value

If OTHER ethnicity please describe:

What specifically are you interested in today?*

How can Final Mile Ink help you?

Select 1 Micropigmentation service you're interested in:*

If more than one, choose additional services in the question below this one...

Select or enter value

If you would like a second service, please indicate here:

If you would like to choose 3 or more services, please indicate at the end of this form, last field...

Select or enter value

If you're a survivor: who is your Oncologist?*

If you're a survivor: who is your Plastic Surgeon?*

SCHEDULE your free phone consultation with Areonip Architect Cathi Locati

The medical office of Final Mile Ink is located on the west coast which is PST (Pacific Standard Time) - 3 hours behind East coast time (EST). Please adjust your call back time accordingly. Cathi will make every effort to reach you on one or the other dates and times you list below. If she is unavailable to schedule your first consultation at either of those times, she will call you during the best part of the day when you might be available...

What is the best part of the day to reach you?*

Please indicate when to call and discuss this form with you:

Select or enter value

Provide two different dates (1st & 2nd priority) WITH specific times in the fields below to call you and discuss this form*

Choose first choice date here:

1st choice time to call:*

Give the specific time to call you on your first choice date from above:

Second choice date to discuss form:*

provide 2nd choice date here:

2nd choice time to call:*

Give the specific time to call you on your second choice from above:

Survivors: Which type are you? Bilateral or Unilateral?*

Please indicate if you have had bilateral (double - both breasts) mastectomy or unilateral (single - one breast) mastectomy

Select or enter value

eMail address:*

Please provide an email address you check daily

cell phone #:*

2nd phone # other than cell

Please provide a 2nd number where you can be reached when you cant be reached by cell. Your home # or family #

Street Address*

mailing address, same one used for health insurance claims

City*

same city used for health insurance claims

State*

State where you live, same used for health insurance claims

Zip code*

History - What is your story?*

Starting with the month/year of your FIRST cancer diagnosis, briefly describe your medical scenario. What happened, in what order? Describe the solutions and/or surgeries you chose and where are you now in terms of status? If not about cancer, tell your story...

Medical condition*

Please indicate how you are feeling now:

Select or enter value

Ready, set, go?*

Please indicate if are you ready for Micropigmentation now within the next week or two. If you are not ready yet, please indicate a time in the future when you feel you will be ready.

Hair color*

Please tell Cathi the real color of your hair WITHOUT dye - important for ink matching purposes.

Skin color*

Describe the color of your skin in your opinion. Any skin issues to report?

What is the condition of your skin?*

Do you have any special conditions that Cathi should be aware of? Do you have sensitive skin, or prone to bruising, rashes? Are you able to wear regular bandages?

Do you have Health Insurance?*

Select or enter value

Insurance Co. Name

If you have health insurance...

Do you have out of network benefits?

Select or enter value

If you have out of network benefits...

have you met your deductible for this year?

Select or enter value

Survivors: How do your breasts look now, today?...

If you have breastmounds and/or implants...*

What size bra do you wear? What size are your breasts?

Preferred Areola size?*

If you're interested in receiving the cathi.ink Areola Procedure, what size areola / nipple complex do you want?

Select or enter value

Preferred Areola color?*

If you're interested in receiving the cathi.ink Areola Procedure, what color areola's would you like? Cathi can create absolutely any color mix you want...

Select or enter value

Do you wish to have Montgomery Glands created inside the areola or no?...*

Montgomery Glands are the light and/or dark colored "bumps" found inside the areola itself (they are not the nipple - the nipple is found at the center of the areola). The cathi.ink Areola Procedure includes the artistic version of the glands and allows the areola's to appear incredibly real and round instead of flat. Cathi can create standard, flat or 3D areola's - whichever you prefer...

Select or enter value

Breast symmetry*

Are both of your breasts fairly the same size and equal to each other?

Select or enter value

Asymetrical, uneven breasts

If one of your breasts is bigger or smaller than the other, please explain and describe your current breast situation and how you would like that changed / fixed?

Areola / Nipple Repair (botched breast surgery)?

If you are in need of repair work to your areola's and nipples after reduction or enlargement surgery has left you with breast problems, please explain what you hope to achieve with Micropigmentation:

Attach photos of your breasts:

Before the first phone call, Cathi reviews your current breast situation photos for assessment. Using the file attachment upload link below this question, attach your photos. Instructions: Take a 'breast-selfie' and send at least one photo that is in SHARP FOCUS of both of your breasts in the same photo (send a full frontal photo: with your camera in selfie mode, hold both arms straight out in front of your breasts, NOT TOO HIGH NOT TOO LOW to get best shot of full chest. The light should be shining ON YOUR BREASTS not light behind you. Dont shoot in a yellow bathroom. Use natural light in front of a window. Take a closeup of the right areola/nipple and breast then take a photo of the left areola/nipple and breast. Send those 3 photos - they must be in focus! Please check quality before uploading - if they are blurry please take them again.

File Attachments

Drag and drop files here or

Do you have a regular tattoo?*

If no please indicate. If yes, did you have any adverse (bad) affects from it?

Do you have diabetes?*

If no please indicate. If yes, please provide the name and contact information of your doctor who manages your diabetes for medical release.

Anything else you would like to add?

If you would like a 3rd or 4th Micropigmentation service indicate here, otherwise write anything you'd like...

Thank you for taking the time to provide detailed answers to these questions!

You have created a client portrait for Cathi to best understand the picture of you during your consultation session over the phone. Cathi is looking forward to speaking with you about gorgeous full-color fine art solutions in permanent ink that will last forever. Cathi will call you asap once you have submitted this form.

Send me a copy of my responses

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