Kally's Balance Paid - Areola Tattoo Application Form - Post Mastectomy

Please fill out the following form to help us understand your physical condition and personal circumstances to determine if you are a candidate for the Balance Paid Clinic - post mastectomy.

Once you have submitted the form, we will be in touch to let you know if you have been successful. If you are unsuccessful, there are other options to help you fund your treatment.

This application is open to our approved surgeon referrals. If you have not been referred to by our approved surgeons, please do make a note of this on your form, with the details of your surgeon and hospital.

Email

First name

Last name

When you have completed this form, you will receive a copy to your email address. When you receive this, please check your answers and then please EMAIL your form to: info@kally.co.uk

By emailing your form to us, this will speed up the process - thank you

Phone

Address

Have you been referred by a surgeon? If yes please name your surgeons.

If you have not received a surgeon referral, please give details of your hospital and surgeon for our records

How long ago was your last surgery

Under 6 Months

6-12 Months ago

12 Months or more

Details of your surgery 1) Is your surgery following breast cancer detection? 2) If your surgery following BRCA or genetic testing and elective surgery? 3) Please detail your specific reconstruction - for example DIEP Flap, Implants, Exanders etc.

Name of Hospital where you were treated

Name of Surgeons, Oncologists, Plastic Surgeons and Referral names

Are you intending on having further surgery? If yes please explain below. This may be fat grafting or a nipple surgery

Have you had a Tattoo on the area before? If yes please detail below: Please include DATE of tattoo and the name of the artist or hospital where it was done

Do you have private medical insurance?

Yes

No

Other

Did you receive your treatments via the NHS or was this via Private Medical Insurance (please say yes even if the medical insurance has expired)

Now, a little bit about your personal circumstances. We would like to let you know no one funds these treatments; Kally does not make a claim to any charity or trust to cover these treatments. We really do offer these for free; therefore, we must be quite thorough with our questions, which means we can help those who really do need a free treatment.

Occupation

Your Age

Are you at pension age, and are you claiming your pension?

Yes

No

Are you claiming any government benefits?

Yes

No

Income Earnings - please include joint earnings if you are in a household with a partner

Please explain why you would be a great candidate for this free tattoo service. Sometimes, fitting into a box by answering standard questions does not give the whole picture. We would love to hear your story to make a better decision.

Signature

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Application Date

Day

Month

Year

Balance Paid

Application form

Kally's Balance Paid - Areola Tattoo Application Form - Post Mastectomy