Feedback
Your feedback is important. Thank you for completing the online focus group survey and sharing your experience about “wearing” an areola tattoo. All personal information collected will be kept confidential.

If you would like to participate in follow-up research such as evaluating additional prototypes, colours, styles, please check here

We really appreciate your participation. Once we have received your completed survey, you will be sent your choice of any ONE sheet.
Please choose 1 sample sheet*:
Light skin-tone Medium skin-tone Dark skin-tone
Regular price is $15.99 USD per sheet plus FREE shipping!
Personal Information
Saluation:
If other, please specify:
First Name: *
Last Name: *
Address: *
Apt/Suite:
City: *
State/Province: *
Country:
Zip/Postal Code:
Home Phone:
Mobile/Cell Phone:
Work Phone: Ext:
Email: *
Demographic Research *
Skin Tone/Colour:
If other, please specify:
Your Background:
(select all that apply)		 Medical Professional Undergoing Treatment Breast Cancer Survivor Family/friend of breast cancer patient
Breast Cancer Demographics:
(select all that apply)		 Had Mastectomy Mastectomy Planned Had Radical Mastectomy Radical Mastectomy Planned
Had Breast Reconstruction Breast Reconstruction Planned Chemotherapy Treatment Radaition Treatment Other Treatment Not Applicable
Survey *
1) Do you have a nipple?
Other Comments:
2) Would you wear this Areola Temporary Tattoo?
Other Comments:
3) Does it look like a real areola on the paper?
Other Comments:
4) When would you "wear" it?
(select all that apply)		 Intimate Moments With T-Shirt Dressing Up/Special Occasions
Gym/Swimming/Sporting Activities (including communal showers)
Other Comments:
5) You can wear this temporary Areola Tattoo after a mastectomy and before reconstruction. Would you want to?
Other Comments:
6) How would having an areola again make you feel? (select all that apply):

Increased Self-Confidence Look Better Feel More “Normal”
Improved Appearance (when you look in the mirror)
Other Comments:
7) Do you feel your partner would think your breast(s) look more “normal”?
If other, please specify:
8) When you told your partner about the areola tattoo what was his/her reaction? (select all that apply)
Other Comments:
9) Did you experience eyebrow hair loss during your chemotherapy treatment?
Other Comments:
If you have tried  ‘wearing’ the areola tattoo prototype, please answer the following:
10) Does it look "real" when you wear it?
Other Comments:
11) Were the application instructions helpful?
Suggested Revisions:
12) Approximately how long did it take you to apply the first areola tattoo?
If other, please specify:
13) If you applied the second tattoo how many minutes did it to do it?
If other, please specify:
14) How many days did your tattoo last? (Tips: Areola Tattoo lasts longer when gently washed with non-oil
                                                                             based soap AND turn your back to the water faucet/source.)
If longer, please specify:
15) What was your partner's reaction to your appearance?
(select all that apply)		 Good Fantastic No Difference Appearance is more sexually attractive to him/her
Thinks you feel better/have more confidence Other
If other, please specify:
16) What were your partner's feelings about you wearing the areola temporary tattoo?
(select all that apply)

Good Fantastic No Difference Appearance is more sexually attractive to him/her
Thinks you feel better/have more confidence Other

If other, please specify:
17) Would you recommend the areola tattoo prototype to a friend?
If other, please specify:
Comments
Do you have any questions?
Do you have any additional comments about the areola tattoo?
Submission
Contact Us:

Email:  inquiries@areolatattoo.ca
Phone: 416.972.7636  
Toll Free: 1.877.972.7636
Submit: