Download Patient Referral Form – Oregon

Patient Profile for Referral to Breast Friends Resources:
□Female □Male Age_______
□Newly Diagnosed/In Treatment
□Breast □Ovarian
□Cervical
□Uterine
Referral Date:_______
□Completed Treatment
□ Other Cancer
Notes:
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Breast Friends Support Services Available:
□ Phone, or in-person, one-on-one support with survivor volunteer
□ Accompany patient to chemotherapy appointments (available in the greater metropolitan Portland area)
□ Monthly group support meetings (multiple locations) – Some are evenings, or afternoons, one is breakfast.
□ Thriving Beyond Cancer – three-day retreat or two-day workshop facilitated by Certified Life Coach Sharon
Henifin. This workshop is for women who have completed formal treatment. Purpose is to help women gain
clarity and create a more fulfilled life after cancer. There is a modest charge to cover food costs, lodging and
materials. Scholarships are available. (Program brochure available)
Additional Resources Available:
□ Our ‘Signature’ Humorous baseball caps for chemo patients
□ Closet with scarves, wigs, mastectomy bras, and prosthetics, provided to patients at no charge – Tigard
Office.
□ Matt’s Chemo Bags full of goodies to take to chemo treatment.
□ Printed guides for family, friends, co-workers and spouse/partners, kids/teens, filled with ideas on how to
best support the patient.
Referring clinic or medical office:
Referring Physician:
Patient Name:
Patient Phone Number:
Patient email:
Patient Address:
Instructions: Medical doctor or P.A. – Fill out (with patient permission), and please fax to 1-866-734-3762
Breast Friends
503-598-8048; Toll Free 888-386-8048
www.breastfriends.org, [email protected]
14050 SW Pacific Hwy, Suite 201, Tigard, OR 97224