REVIVE + THRIVE EVENT Application
This Application Form information will be submitted and you will be contacted by October 20 by EMAIL info@outlinerstudio.com. This application and the steps below will determine who receives their FREE Ultra Realistic Areola Tattoo & Medical Art Services. We look forward to speaking to you soon!
IN ORDER TO APPLY
1. Fill out this application below. 2. Follow our Social Media Pages on Instagram and Facebook @outlinerstudio. 3. Like our Revive + Thrive Social Media Post. 4. Share our Revive + Thrive Post in your stories/feed. 5. Fill out your Client Intake Forms. All spaces must be filled out in order to submit.
Breast Cancer Survivor Name
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First Name
Middle Name
Last Name
Birth Date
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Please select a month
January
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Please select a year
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What describes your need for our Medical Art services best? (Select ALL that apply)
*
I need bilateral Ultra Realistic Areola Tattoo
I need unilateral Ultra Realistic Areola Tattoo
I lost my brows due to breast cancer and chemotherapy and need PMU brow services
I need Scar Camouflage services due to breast cancer
Other
Are you currently under the care of a Physician in regards to any major medical issues? (Diabetes, heart disease, joint replacement, currently undergoing chemotherapy or radiation)
I have none of the major medical issues listed above
I am currently being treated for one or more of the medical issues listed above
Have you had breast surgery within the past 6 months?
*
I have had breast surgery within the past 6 months
I am currently undergoing chemotherapy or radiation
It has been >6 months since my last surgery, and I am cleared by my surgeon to receive Ultra Realistic Areola Tattoo & Medical Art Services
Have you read over all pre procedure, aftercare, and our policies?
*
Yes, I have read, accept, and agree
No, I have not read this information provided by this website.
E-mail
*
example@example.com
Mobile Number (must be able to receive text messages)
*
Please tell us a little bit about you!
*
I do realize that there are limited appointments available. Also, I understand that by submitting this application does not mean that my appointment is scheduled or accepted. Please understand that at booking, we will require a $50 deposit to hold your spot, and to make sure you are serious about scheduling this appointment. (No showing or last minute cancellation to this appointment will mean that someone else will not receive this free gift!) This deposit will only be refunded after you have shown to your appointment time or cancelled >48 hrs in advance.
*
I accept, agree, and understand
I do not agree
Submit Application
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