Friends Like Me2 – Request Form - PA Breast Cancer Coalition

* First Name

* Last Name

* Street

No PO Box addresses - the PBCC sends out care packages through UPS and must have a street address.

Street 2

* City

* State

* Zip Code

Email

Phone Number

xxx-xxx-xxxx

Date of Birth

mm/dd/yyyy

Yes, I would like to receive e-mail from PA Breast Cancer Coalition

Yes, I would like to receive postal mail from PA Breast Cancer Coalition

* Diagnosis Date

mm/dd/yyyy

* What type of breast cancer?

If other, please explain.

T-Shirt Size

Have you been diagnosed with Metastatic or stage IV Breast Cancer?

Yes
No

Have you received a Friends Like Me care package in the past?

Do you have a partner/caregiver?

Yes
No
Unknown

If so, please choose the option that best describes your caregiver

Spouse
Parent
Child
Sibling
Friend
Other

If other, please specify

Do you have insurance to cover the cost of treatment and medications? ***If you are uninsured or underinsured, request a call with our Patient Advocate who can provide you with resources to help with coverage

Yes
No
Unknown

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

* Would you like the PBCC's patient advocate to call you?

* Phone Number To Call You At

xxx-xxx-xxxx

Do you have young children at home?

Yes
No
Unknown

If yes, please describe.

Is the recipient sensitive to scented items?

Yes
No
Unknown

Comments

Friends Like Me2 – Request Form

Friends Like Me2 care packages have been carefully produced to address the needs of recipients diagnosed with metastatic or stage IV breast cancer. The materials are designed to support survivors and thrivers facing a metastatic diagnosis.