Recommended Post-mastectomy Tattoo Form

You’ve made it this far, it’s exciting! I realize how big of a deal it is to do this, and I thank you. Thank you for including me and taking the time to share your story through this form. The more information I have, the better I can help you and/or point you in the right direction in regards to tattooing.

The majority of my clients travel in from all over the world. But I’m keeping a certain amount of days open for clients connected to the Lynn Sage Breast Center and Northwestern’s Prentice Women’s Hospital. This form is private and has been created for patients who have been recommended.

Please Read before submitting form…

  1. Tattoos must be a minimum of one year after your most recent surgery. We can book up to six months in advance, so if the timing works, please submit!

  2. PHOTOS - After you submit this form, please email photos of yourself to - Use your name as the subject of the email. One straight on photos of your healed self, and another one from a slightly turned view. You’re welcome to include any other photos you deem relevant as well. We realize how vulnerable and odd it feels to send these photos. Be assured we take this seriously and confidentially. Being able to see your scarring helps the entire process.

  3. Pricing is between $1600-$2500 and takes place in one full day. (Once accepted, a deposit is required to secure the appointment)

Name *
(Doctor's name)
Date of most recent surgery *
Date of most recent surgery
*Date of tattoo must be at least one year after final surgery.
Can you briefly describe all of your procedure(s)? Type of reconstruction? (radiation, chemo, drug therapy, etc.)
(Single or double mastectomy? Current bra size, if applicable? Anything else you can think of...)
Use this space to include any other personal information you'd like for me to know about you! (not required)
Cell phone *
Cell phone
You'll probably have to cater to my schedule, but we try to help. What days of the week (M-F) are best for you?
Experience *
Do you have other tattoos?