Perky Restoration Program Application

Perky Restoration Program

Pink Warrior Advocates and Perky have teamed up for the Perky Restoration Program, aiming to help breast cancer warriors reclaim something that cancer took—completely free of cost for warriors whose application has been approved. Please complete this application to be considered.
GUIDELINES

Selected warriors in the Perky Restoration Program are eligible to receive a complimentary treatment from Perky, such as nipple restoration, eyebrow tattooing, or scar camouflaging. This is a one time benefit for receipients. Selection is based on when the warrior receives post-surgery or treatment clearance from their doctor. If selected as a recipient, Perky will collaborate with you to create a treatment plan within the program's budget.

This program is intended to assist those who are experience financial distress from their cancer diagnosis so please keep that in consideration before applying for this program.

Once approved and selected, you’ll be notified and connected with Perky, who will reach out directly to schedule your treatment.

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ELIGIBILITY REQUIREMENTS
- Medical Verification Form confirming a breast cancer diagnosis or a genetic mutation for previvors must be on file before scheduling a tattoo appointment. [Click here to download Medical Verification Form]
- Medical clearance is required for applicants undergoing active treatment.
- Eligible applicants must reside in one of the following counties:
  Comal, Guadalupe, Bexar, Travis, Hays, Bastrop, Caldwell, Medina, Wilson, Bandera, Kerr, Kendall, Blanco, Gillespie, Llano, Burnet, Williamson, Lee, Gonzales, Atascosa, Karnes
Eligibility timelines by treatment type:
- Surgery: Wait 3–4 months post-surgery'
- Radiation: Wait 4–6 months post-radiation
- Chemotherapy: Wait 6–9 weeks post-chemo
- Brows: May be tattooed before chemotherapy starts
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Due to high demand, completing an application does not guarantee selection for the Perky Restoration Program.

REQUEST FORM
Warrior Name:*

First NameLast Name
Warrior Email:*
example@example.com
Warrior Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Warrior Date of Birth:*

MonthDayYear
Date
Warrior Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Diagnosis: *

MonthDayYear
Date
Tentative eligibility date to be cleared to receive tattoos based on the guidelines above:*

MonthDayYear
Date
Please select the treatments you that you would be interested in:*

Unilateral NippleBilateral NipplesEyebrowsScar Camouflaging
Please share more about your breast cancer journey, including any surgeries or treatments you have undergone or have scheduled. Be sure to include specific dates if possible.*
Which Perky treatments are you interested in? Please list them in order of preference and provide details on why each is important to you. While not all treatments may be covered, if selected, we will work with you to create a treatment plan that aligns with the program’s budget.*
This program is designed to support individuals facing financial hardship who would otherwise be unable to access services from Perky. We’d love to hear about your journey with breast cancer and how it has impacted you financially.*
If selected, are you comfortable sharing your experience as a recipient of the Perky Restoration Program to help us raise funds and awareness for this program?*
This program relies on ongoing funding to help more breast cancer warriors feel beautiful and supported. Would you be willing to share a donation link to help us continue this mission?*
Please upload a copy of a valid ID:*

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Please upload a your Medical Verification Form:*

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If in active treatment, please upload your letter stating your medical clearance:

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How did you hear about this program?*
Dr. Office / Social Media / Google Search / Etc.
ACKNOWLEDGEMENT
I acknowledge that I have read and understand the program guidelines and accept that submitting an application does not guarantee selection.

YesNo
CERTIFICATION
I certify that the information in this application is true and correct to the best of my knowledge. I understand that the information provided may be verified by Pink Warrior Advocates and I authorize them to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide untrue information in this application, I will be ineligible for the Perky Restoration Program. Any payments for treatments performed by Perky will be billed to me, and I will be responsible for payment of the bill(s).

YesNo
Signature*
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Perky Restoration Program

GUIDELINES

REQUEST FORM

ACKNOWLEDGEMENT

CERTIFICATION