∞ Everything you tell us stays strictly confidential — seen only by our team. With gentleness, and never asking you twice.
About you
Full name *
City *
Email *
Phone *
Age
How did you hear about us?
What you need
Your medical history, briefly
Have you finished treatment / is the skin healed?
Choose...
Yes, treatment is finished
I'm still in treatment
I'm not sure
We only work on fully healed skin, with your doctor's approval — for your safety.
The hospital / clinic where you were treated
Your attending doctor
A photo
A photo of the area
📷 Upload a photo
Breast/areola, eyebrows or scars — it helps us understand your case. Strictly confidential, seen only by our team.
At your appointment we take before and after photos together — they are part of documenting the process (it's how we show, with respect, that the reconstruction really happened). If you'd like, you can also upload a photo now.
Anything else you'd like to tell us? (optional)
Your consent
Do you allow us to share your story publicly? (optional)
Choose...
Yes, but without my face
Yes, including my face
I'd rather not, for now
Your agreement helps us enormously: every story shared brings more supporters — and more women helped. You choose how.