Survivor Membership Form – ARCHIVE

First Name:

Last Name:

Are you an ovarian cancer survivor?

Birthday:

Email Address:

Home Number:

Cell Phone Number:

Address:

Address 2:

City:

State:

Zip/Postal Code:

Country: (Please note, we can only ship within the United States at this time)

Is this your mailing address? If not, please write your mailing address below:

Current Age:

Age first diagnosed:

Ethnicity:

Do you have children?

Are you currently in treatment?

Type of treatments you’ve had:

Chemotherapy

Radiation

Surgery

HIPEC

Other

Have you ever had a re-occurrence of ovarian cancer?

If yes, how many re-occurrences?

Last treatment date:

Location where you get treatment: (if applicable)

How was your hair before and after treatment?

Have you ever had any genetic testing done?

Has anyone in your family had any genetic testing done?

Are you BRCA or Lynch Syndrome positive?

Have you ever had genomic testing for biomarkers in your tumor?

Have you ever participated in a clinical trial?

Are you interested in learning more about clinical trials?

Have you every gone to an ovarian cancer support group?

Are you interested in joining an ovarian cancer support group?

Are you interested in learning more information about support groups for your family?

What changed for you after treatment?

Best way to reach you:

Best time to reach you:

Types of packages you are interested in:

Beauty aids

Support

Art therapy

Holistic/Wellness

Other

The questions below are to create a package to best fit you:

T-shirt size:

Eye color:

Hair color:

Skin color:

Favorite color:

Hat size:

Shoe size:

Things you like:

Adventure

Outdoors

Home

TV/ movies

Shopping

Spa days

Exercise

Other:

Interests in general:

Travel

Family

Sports

How did you hear about the T.E.A.L. ® Amazing Lady Membership?

Additional Comments:

By checking this box, I attest that the information above is true.

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