Final Mile Ink

Patient Portrait

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.

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

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

Who referred you?

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

Month, day and year you were born

How old are you now?

How can Final Mile Ink help you?

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

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

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...

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

Choose first choice date here:

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

provide 2nd choice date here:

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

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

Please provide an email address you check daily

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

mailing address, same one used for health insurance claims

same city used for health insurance claims

State where you live, same used for health insurance claims

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...

Please indicate how you are feeling now:

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.

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

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

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 out of network benefits?

have you met your deductible for this year?

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

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

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

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 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...

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

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?

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:

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.

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

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

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

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.

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