SEND A MASTECTOMY BASKET FORM

WHO IS A CANDIDATE?

PRE-OPERATION MASTECTOMY PATIENTS

Our Bosom Buddy Baskets are personally created by a small group of caring women. The Baskets are specifically made for Pre-Operation Mastectomy Patients awaiting breast cancer mastectomy surgery and are designed to be most useful during the first Five Days Post Operation with items used in the immediate recovery process following mastectomy surgery.

Our Bosom Buddy Baskets are Not designed or intended for patients that have already had Mastectomy surgery or other breast cancer treatments such as lumpectomies, chemo or radiation.

If you or someone you know are a candidate, request a Bosom Buddy Basket Below.

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BOSOM BUDDY BASKET REQUEST FORM

Diagnosis - The IIIB's Foundation is a local non-profit organization dedicated to comforting women going through breast cancer by providing our Bosom Buddy Baskets created specifically for mastectomy surgery patients. We are happy to provide our Bosom Buddy Basket to you at no charge. Please fill out the items below and we will ship you basket to you!

Date of Mastectomy:

Hospital Name Where Having Surgery:

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FIRST NAME of Basket Recipient:

LAST NAME of Basket Recipient:

Country of Delivery: USOther

Basket Recipient Street Address 1:

Basket Recipient Street Address 2: (if applicable):

Basket Recipient Street Address 3: (if applicable):

Basket Recipient City: State: Zip Code:

Basket Recipient Phone: (Please enter your phone if you do not have theirs)

Phone Extension: (if applicable):

Is this a Residential Address? (We cannot deliver to any hospital that we are not connected to as the basket gets lost in transit) To confirm this is a Residential Address, Please check "1": 1

Basket Recipient Email: (Please enter your email if you do not have theirs)

(Required) HOW DID YOU HEAR ABOUT US? Please let us know who referred you:

NOTE TO THE IIIB's FOUNDATION:

Please use "SEND REQUEST" BUTTON

Some items in Basket will change from time to time from the pictured basket.

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