i want to be a sister

Want To Be A Sister

Thank you for contacting Breast Connect, Inc. and for your interest in volunteering for our Sisterhood Program. Please submit the following email form and we will contact you with additional information. And if you haven’t already, please join our Facebook page at @breastconnect.

    Name*
    Email*
    Phone*
    Date of birth
    Marital Status
    MarriedDivorcedWidowedSingle
    Race
    CaucasianAfrican-AmericanHispanicOther
    Kids & Ages
    Date of Diagnosis
    Size of Tumor
    DCIS/Invasive/Lobular
    Stage
    Receptor Status (ER+, Triple Neg, etc):
    Oncotype DX (if tested, please list #)
    Single Mastectomy
    YesNo
    Bilateral Mastectomy
    YesNo
    Lumpectomy
    YesNo
    Radiation (if yes, please list number of treatments)
    Hormone Therapy (if yes, please list drug)
    Type of Reconstruction (if any)
    Chemotherapy (if yes please list type and # of treatments)
    BRCA Positive (if yes, please list 1 or 2)
    Lymph Node Involvement
    YesNo

    Metastatic Disease (if yes, where?)
    Treatment
    Estrogen Blocker (ex: Tamoxifen)Aromatase Inhibitor (ex: Arimidex)ChemoNeoadjuvant ChemoHerception and PerjetaRadiation
    Please let us know your preferred method of contact and please know someone will contact you within 72 hours.

    Sister Survivor Disclaimer

    The Breast Connect Sisterhood matching service is provided for the benefit of new breast cancer patients, with no compensation to either party. All interactions resulting from the connection between you and your “sister match” are personal and at the discretion of the new patient and survivor sister. Breast Connect is held harmless from any and all interactions and decisions resulting from the match. You hereby release and agree to indemnify and hold harmless Breast Connect, Inc. and its members, officers, directors, employees, and agents from and against any and all claims, liabilities, and damages arising out of the sharing or storage of any information you provide to us and from the interactions with persons with whom you connect through Breast Connect, Inc.

    BreastConnect.org has not been established to sell healthcare, drive opinions, or be a persuasive source. By submitting a request to participate in the Breast Connect Sisterhood program, you are authorizing Breast Connect, Inc. to store your information in a database and, as appropriate, share the information you provide (including, without limitation, your name, medical diagnosis and contact information) with new patients seeking to participate in the Breast Connect sisterhood program.


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