Request Form – for a Loved One - PA Breast Cancer Coalition

Recipient Information

Name*

First Last

Street Address*

No PO boxes please - packages shipped via UPS

Street Address 2

City (must be in Pennsylvania)*

State*

Zip code*

Email

Phone

Date of Birth

MM

DD

YYYY

Diagnosis Date*

Type of Breast Cancer

Please list type

T-shirt size

Has the recipient been diagnosed with stage IV metastatic breast cancer?

Yes
No
Unknown

Do the recipient have a partner / caregiver?

Yes
No
Unknown

Please choose the option that best describes the recipient's caregiver.

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

Yes
No

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

Will the recipient be receiving chemotherapy?

Yes
No
Unknown

Will the recipient be receiving radiation?

Yes
No
Unknown

Will the treatment require surgery?

Yes
No
Unknown

Is this a recurrence?

Yes
No
Unknown

Does the recipient have young children at home?

Yes
No

Please list ages of children

Is the recipient sensitive to scented items?

Yes
No
Unknown

Additional comments:

Sender Information

What is your relationship to the patient?*

Name

First Last

Street Address*

Street Address 2

City, State*

Zip code*

Email

Phone number

Date of birth

MM

DD

YYYY

Are you a breast cancer survivor?

Yes
No

Would you like to receive emails from the PA Breast Cancer Coalition?*

Yes
No

Would you like to receive mail from the PA Breast Cancer Coalition?*

Yes
No

*

I certify that the recipient of this care package lives in Pennsylvania.

Request Form – for a Loved One

Friends Like Me Care Package Request Form

Recipient Information

Sender Information