Self-Request Form

Friends Like Me® Care Package Self-Request Form

Fields marked with an asterisk (*) are required.

Friends Like Me^® care packages have been carefully customized to address the needs of Pennsylvanians diagnosed with breast cancer within the last six months. The materials are designed to support the patient in a timely manner during those critical first few months when she/he is dealing with a new diagnosis and making decisions about treatment options. Please review eligibility requirements:

• The Friends Like Me^® care package must be sent directly to the patient.
• The recipient must live in Pennsylvania.
• If you are requesting this care package for a loved one, please use the form found opens in a new windowhere.
• If you have been diagnosed with Stage IV metastatic breast cancer, please select “Stage IV metastatic” from the “Breast cancer stage” options.

Name(Required)

First Last

Address(Required)

Please note, unfortunately we are unable to mail care packages to P.O. box addresses.

Street Address Address Line 2 City (must be in Pennsylvania) AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Email

Phone

Date of Birth

Month

Day

Year

Diagnosis Date(Required)

MM slash DD slash YYYY

Type of breast cancer(Required)

Please select one

Ductal carcinoma in situ (DCIS)

Lobular carcinoma in situ

Invasive ductal carcinoma

Invasive lobular carcinoma

Inflammatory breast cancer

Triple-negative breast cancer

Unknown

Other

Please describe:

Breast cancer stage(Required)

Stage 0

Stage I

Stage II

Stage III

Stage IV metastatic

Unknown

This field is hidden when viewing the form

Please list type

Do you have a partner / caregiver?

Yes

No

Please choose the option that best describes your caregiver.

HusbandWifeParentChildSiblingFriendOther

Do you have insurance to cover the cost of treatment and medications?

Yes

No

If you are uninsured or underinsured, request a call with our Patient Advocate who can provide you with resources to help with coverage.

Are you currently receiving or do you plan to receive chemotherapy?

Yes

No

Unknown

Are you currently receiving or do you plan to receive radiation?

Yes

No

Unknown

Will your treatment require surgery?

Yes

No

Unknown

Is this a recurrence?

Yes

No

Unknown

Do you have young children at home?

Yes

No

Please list ages of children

Would you like the PBCC's Patient Advocate to call you?

Yes

No

Are you sensitive to scented items?

Yes

No

Thrive Causemetics® has generously donated shades of its Buildable Blur™ HD Creaseless Concealer for our care packages. If you wish to receive this item, please select the closest shade to your skin tone. Available colors are marked with a pink ribbon in the image below.

Light Medium (cool pink undertones)

Medium Tan (cool pink)

Rich (warm golden)

Deep (warm golden)

Very Deep (cool pink)

Very Deep (warm golden)

Additional comments:

(Required)

I understand that this program is for residents of Pennsylvania only.

Submit