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

Share With Friends

Friends Like Me Care Package Self-Request Form

 

Fields marked with an asterisk (*) are required.

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:

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Name:

 

 

   

 

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City/State/ZIP:

 

    

 

 

Date of Birth:

 

 

 

What's this?

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(Maximum response 255 chars, approx. 5 rows of text)

 


 
Question - Not Required - Do you have a partner/caregiver? :



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



 
Question - Not Required - Are you currently receiving or do you plan to receive chemotherapy? :



 
Question - Not Required - Are you currently receiving or do you plan to receive radiation? :



 
Question - Not Required - Is this a recurrence? :



*
Question - Required - Would you like the PBCC's patient advocate to call you? :


 
Question - Not Required - Do you have young children at home? :



 

 

   Please leave this field empty