Finding a cure now...so our daughters won’t have to.

Share With Friends

Request Form

 

Fields marked with an asterisk (*) are required.

Recipient Information:
Friends Like Me care packages have been carefully produced to address the needs of recipient diagnosed with breast cancer within the last six months. The materials are designed to support the new patient in a timely manner during those critical first few months when she is dealing with her diagnosis and making decisions about treatment options.

  • Please review the eligibility requirements
  • The Friends Like Me care package must be sent directly to the survivor.
  • You may request a Friends Like Me™ care package for yourself.
  • We customize each care package according to the specifics of the recipient's situation.
 

Recipient's Information

  Contact Information:

*

Name:

 

 

   

*

 

*

City/State/ZIP:

 

    

 

 

Date of Birth:

 

If you respond and have not already registered, you will receive periodic updates and communications from PA Breast Cancer Coalition.

 

 

What's this?

*  


 


 
Question - Not Required - Does the recipient have a partner/caregiver? :



 
Question - Not Required - Does the recipient have insurance to cover the cost of treatment and medications? :



 
Question - Not Required - Is she currently receiving or does she plan to receive chemotherapy? :



 
Question - Not Required - Is she currently receiving or does she plan to receive radiation? :



 
Question - Not Required - Is this a recurrence? :



*
Question - Required - If this is a self-request, would you like the PBCC's patient advocate to call you? :


 
Question - Not Required - Are there young children at home? :



 

 

Sender Information

*  


*  


*  


   


*  


*  


*  


*  


*  


   


 


 

*


*


   Please leave this field empty