SuMa Ink Appointment Request Form

Appointment Request Form

Thank you for your interest in SuMa Ink and the invitation to be part of your restorative care team! We recognize that this is a deeply personal process, and we use this form to gather all of the necessary information we need to get the ball rolling.

Before filling out and submitting this form, we strongly encourage you to review our FAQ's HERE! Our website also has information about the paramedical tattoo process, what to expect during your appointment, a bit of iniformation about the Women's Health and Cancer Rights Act (WHCRA) and possible reimbursement for mastectomy/reconstruction patients. The majority of client's initial curiosities and concerns can be answered there, and anything else we can discuss as we move forward!

Please answer all questions below to the best of your abilities. We welcome the opportunity to meet you and to work together soon.

Client Name*

First NameLast Name

Phone Number*

Format: (000) 000-0000.

Email *

example@example.com

Briefly describe the type of surgery you had (if applicable) along with the goals you would like to achieve with restorative tattooing. Expectations will be discussed further, but this is a great starting point to see where you are now, and where you'd like to be!

Which paramedical tattoo service are you interested in?

Mastectomy TattooNon-mastectomy Tattoo (non-mastectomy related breast tattoo, revision of existing nipple/areola tattoo, etc.)

Please select that date of your last surgical procedure.*

For Mastectomy:*

Unilateral (single breast)Bilateral (both breasts)Not relevant to request

Would you like work done on both sides? (to create matching symmetry, pigmentation, etc. of the nipple/areola complex)*

Yes: I want to have both sides tattooedNo: I only want one side tattooedUnsureNot relevant to request

Did you experience any complications from any surgeries or procedures?*

YesNoUnsureNot relevant to request

If "Yes" or "Unsure," please explain below. If none, please put "n/a."*

Please provide 3 photos for evaluation: 1-Bilateral (from the front) of both breasts 2-Close up of nipple/areola of the left breast 3-Close up of nipple/areola of the right breast. *

We understand the sensitive nature of these images, and all will remain private and secure. For privacy, please do not include full body photos, or photos showing your face.

Will you be traveling from out of town for this appointment?*

YesNo

What is your availability? (Please keep in mind that Friday & Saturday appointments are very limited, so if you do have flexibility on the other days, we appreciate it!)*

SundayMondayFriday *limitedSaturday *limited

Any additional information you would like to share with us?

Specific dates your are interested in or specific questions you didn't see in our website or FAQ's? Let us know here! We'll review your form and aim to respond within 48 hours. You may also text Suzanne directly at (305) 807-2217 to follow up.