Survivor Membership Form First Name: Last Name: Are you an ovarian cancer survivor? Yes No Birthday: Email: Home Number: Cell Number: Address Line 1: Address Line 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: Hispanic African American Caucasian Asian Other Do you have children? Yes No Are you currently in treatment? Yes No 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: Email Mail Text Call Best time to reach you: Morning Afternoon Evenings Weekend 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: Small Medium Large XL XXL XXXL 4XL 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. √
