i want to be a sister

Want To Be A Sister

Thank you for contacting Breast Connect, and for your interest in joining our Sisterhood Program database. Please submit the following form to the best of your ability, and we will contact you when a match is made. If you don’t have the information, please leave it blank. And if you haven’t already, please join our private Facebook group HERE.

    Name*



    Email*


    Phone*



    Date of Birth



    Marital Status
    MarriedDivorcedWidowedSingle

    Race
    CaucasianAfrican-AmericanHispanicOther

    Kids
    YesNo

    Kids Ages
    0-55-1010-1515+

    Date of Diagnosis


    Number of Tumors
    123+

    Size of Tumors (separate each with a comma)


    DCIS or LCIS
    DCISLCISInvasive Ductal Carcinoma (IDC)Invasive Lobular Carcinoma (ILC)Inflammatory Breast Cancer (IBC)

    Stage
    01234

    Receptor Status:
    ER+ER-PR+PR-Her2+Her2-

    Oncotype DX # (if tested)


    Surgery Type
    Single MastectomyBilateral MastectomyLumpectomy

    Radiation
    YesNo

    Hormone Therapy
    TamoxifenArimidex (anastrozole)Aromasine (exemastane)Femara (letrozole)

    Type of Reconstruction
    Flat (no reconstruction)Tissue expander/implantLatissimus dorsi flapTRAM flapDIEP flap

    Chemotherapy
    YesNo

    BRCA 1 Positive
    YesNoN/A

    BRCA 2 Positive
    YesNoN/A

    Metastatic Disease
    YesNo

    Metastatic Disease (If Yes, Where?)
    LungLiverBrainBone


    (Communication) please let us know your preferred method of contact and someone will contact you when there is a match.
    TextCallEmail

    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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