Breast Buddy Support Group
Registration Form


Please note that from time to time, questions will be posed to group members on issues related to Well Being and Breast Cancer, in a bid to measure progress of the group and for research purposes. Kindly take part in such discussions as this is important . This is a requirement to be a member of this group. *
Required
1. Full Names- 1st / middle/ surname. *
2. Date of Birth - Date/Month/Year *
3. Address/ City *
4. Email Address *
5. Phone Number *
6. Relationship Status *
Required
7. Do you have kids and how old are they? If yes how many! Do you want more! *
8. Occupation/ Employment Status *
9. Form of identification *
Required
10. Social Media Handles *
11. Did you get a second opinion and why! *
12. Age/ Year of Diagnosis *
13. Type/Grade/Stage of Breast Cancer e.g. Stage 1 Triple Positive *
14. Type of Breast Cancer Surgery *
Required
15. Type of Breast Cancer Treatment/ Plan *
Required
16. Breast Cancer Details *
Required
17. Number of years post treatment/surgery ? *
18. How did you hear about us ? *
Required
19. Why do you want to join the group ? *
Required
20. Do you have a follow up care plan/ How often is it ? *
Required
21. Do you have any Survivorship Support Services available to you ? *
22. Are you (still) dealing with any side effects of Treatment/Surgery ? *
23. Next of Kin/ Phone Number *
24. Is there anything else you would like us to know ? *
25. All pictures and information are confidential and will be kept safe.I accept terms and conditions *
Required
Please note that from time to time, questions will be posed to group members on issues related to Well Being and Breast Cancer, in a bid to measure progress of the group and for research purposes. Kindly take part in such discussions as this is important . This is a requirement to be a member of this group. *
Required
1. Full Names- 1st / middle/ surname. *
2. Date of Birth - Date/Month/Year *
3. Address/ City *
4. Email Address *
5. Phone Number *
6. Relationship Status *
Required
7. Do you have kids and how old are they? If yes how many! Do you want more! *
8. Occupation/ Employment Status *
9. Form of identification *
Required
10. Social Media Handles *
11. Did you get a second opinion and why! *
12. Age/ Year of Diagnosis *
13. Type/Grade/Stage of Breast Cancer e.g. Stage 1 Triple Positive *
14. Type of Breast Cancer Surgery *
Required
15. Type of Breast Cancer Treatment/ Plan *
Required
16. Breast Cancer Details *
Required
17. Number of years post treatment/surgery ? *
18. How did you hear about us ? *
Required
19. Why do you want to join the group ? *
Required
20. Do you have a follow up care plan/ How often is it ? *
Required
21. Do you have any Survivorship Support Services available to you ? *
22. Are you (still) dealing with any side effects of Treatment/Surgery ? *
23. Next of Kin/ Phone Number *
24. Is there anything else you would like us to know ? *
25. All pictures and information are confidential and will be kept safe.I accept terms and conditions *
Required
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