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NothingPink Support Form
This form is intended to help NothingPink connect with the people we are serving. This data will also allow us to apply for grants and funding opportunities to help sustain our non-profit and to serve the community!
With support from our donors, NothingPink offers individuals of North and South Carolina assistance who are facing the risk of breast or ovarian cancers as a result of a family history or a genetic predisposition.
ELIGIBILITY REQUIREMENTS:
If you have a family history of breast or ovarian cancer, or have tested positive for a BRCA gene mutation, you are eligible to apply regardless of insurance status.
Email *
How did you hear about NothingPink? *
Required
Full Name *
Age *
Email Address *
Street Address: *
City *
State: *
Zipcode: *
Household size (including self): *
Ethnicity *
Do you have insurance? *
Required
Annual Household Income *
Family History of Cancer? *
If yes, relationship to family member and type of cancer:
Have you received a cancer diagnosis?
Clear selection
If yes, type of cancer:
Have you had Genetic Counseling? *
Have you had Genetic Testing? *
If yes, what were your Genetic Testing Results?
Clear selection
What is your current need? *
Required
Anything additional you would like to share with NothingPink Support
A copy of your responses will be emailed to the address you provided.
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