Restorative 3D Nipple & Areola Tattoos

Apply

Grants are available to breast reconstruction patients who live in Miami-Dade, Monroe, Broward and Palm Beach Counties. This program is intended to support individuals who may be experiencing financial challenges during their reconstruction journey. Grants are awarded based on each person’s individual needs and circumstances and applicants are considered without specific income limitations.

Please reach out to us if you have any questions about this application or if you would prefer to submit your application via telephone interview. You may print and mail the form and the information requested. If approved, payment will be made directly to the restorative Medical Tattoo Professional Partner.

Eligiilty & Grant Process

Grant Application

Please complete the application online or download and print a copy to submit.

Full Name

Phone Number

What is your preferred method of communication?

Phone Email Text

Date of Birth

Street Address

Street Address Line 2

State

Zip Code

Diagnosis

Breast cancer Genetic mutation

Date of Diagnosis

Date of last surgery

Tentative Eligibility Date for Restorative Tattooing

Preferred Restorative Tattoo Artist

Do you have health insurance?

Yes No

If yes, does your health insurance cover any portion of your restorative tattooing? Please reach out to your insurance company for this information.

Yes No

If yes, please explain your insurance company's coverage for restorative tattooing.

Has your insurance denied coverage for your planned restorative tattooing?

Yes No

if yes, please upload denial correspondence below.

Restorative Treatment requested:

Unilateral Nipple and Areola Bilateral Nipple and Areola Unilateral touch up Bilateral touch up

Please share your breast reconstruction journey, including any surgeries or treatments. Please include specific dates if possible.

The Pink Glimmers Foundation Essential Restorative Support program is designed to support individuals facing financial hardship. Please tell us how your breast reconstruction journey has impacted you financially.

Please include any other information that you believe the grant committee would be interested in knowing when reviewing your application.

Upload Valid ID

How did you hear about the Pink Glimmers Foundation Essential Restorative Support Program

Would you like to be added to the Pink Glimmers Foundation email list?

Yes No

Acknowledgement

I acknowledge that I have read and understand the Essential Restorative Support Program guidelines and accept that submitting an application does not guarantee that I will be awarded a grant.

Certification

I certify thar the information in this grant application is true and correct to the best of my knowledge. I understand that the information provided may be verified by the Pink Glimmers Foundation and I authorize its representatives to contact third parties to verify the accuracy of the information provided in this application. I understand that if I knowingly provide false information in this grant application, I will be ineligible for the Essential Restorative Support and any grant payments made on my behalf will be billed to me and I will be responsible for payment of the bill(s).

Electronic Signature Agreement: By typing your full name below, you acknowledge that your electronic signature is the legal equivalent of your handwritten signature and that the information you have provided is true and accurate.

Today's Date

The Pink Glimmers Foundation is a fiscal sponsorship fund operating under the Key Biscayne Community Foundation’s 501(c)3 charitable umbrella.