Pink Aid is here to help provide friendship and inspiration through our Warrior's personal experiences. To make the best connection, please provide as much information that you are comfortable with.
How can we support you?
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I am seeking information
I am interested in being matched with a mentor
Please tell us which parameters are most important to you for pairing purposes:
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Diagnosis
Genetics
Surgery
Survivorship
Age
Small Children
Treatment
Treatment Information:
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Chemotherapy
Cold Cap Therapy
Hormonal Therapy
Mastectomy/Lumpectomy
Radiation
Prophylactic Surgery
Patient Information
Date of Birth
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/
Month
/
Day
Year
Name
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First Name
Last Name
Address
City, State Zip
E-mail
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example@example.com
Phone Number
Date of Diagnosis
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Month
/
Day
Year
Breast Cancer Type and Stage:
What is your preferred language?
Additional Information you would like to share with us to help us better understand the support you are seeking:
The best time to reach me:
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9:00 a.m. to 12:00 p.m
12:00 p.m. to 1:00 p.m.
1:00 p.m. to 5:00 p.m.
5:00 p.m. to 8:00 p.m.
Please reach me by:
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Phone
Email
Text Message
Referred by:
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Please Select
Healthcare Provider
Other Breast Cancer Organization
Friend/Family Member
Other
Signature
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Type option 1
Type option 2
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