i need a sister

“There is no family history of breast cancer in my family, so being matched with others diagnosed with the same type of breast cancer was invaluable to me. Breast Connect helped me get through a stressful time of making difficult treatment decisions.”

– Patricia Robledo  /  Knoxville, TN

Diagnosed October 2014

Need A Sister

Welcome to the Breast Connect Sisterhood Program. We realize this may be early in your journey, but please know we are here for you. Please complete the form to the best of your ability as your situation stands now. If you don’t have the information, please leave it blank. Once you have submitted the form, we will find a sister survivor who best matches your criteria and provide you with her contact information. And if you haven’t already, please join our 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 add any additional comments regarding your diagnosis that would help us find an accurate match for you. Someone will contact you within 72 hours)
    TextCallEmail




    Additional Comments (if any)



    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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