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FRIENDS IN PINK
(FORMERLY KNOWN AS FRIENDS HELPING FRIENDS WITH BREAST CANCER
Friends In Pink is an organization that raises money for those in the Roxborough
Manayunk Community who are dealing with breast cancer. Our goal is to be able to
provide assistance with co-pays, transportation, child care and all the "little" things
that people need to deal with while trying to cope with this awful disease. This is a
grant and does not need to be repaid. Your name and information will not be
released or shared with anyone. If you think that you qualify please complete the
application and return it to:
Friends In Pink
P.O. Box 35082
Philadelphia, Pa 19128
215-483-0592 and/or [email protected]
PATIENT INFORMATION (please print clearly)
First name: _________________________ Last name: _____________________Today’s date:
________________
Address: _________________________________________ City, State,
Zip:________________________________
Phone number: Home ( ) _____________________________ Work ( )
___________________________
Cell ( )_________________________ Email Address ______________________________
Date of birth: _____________ If patient is a minor (under 18), name of parent or guardian:
_________________
Male Female 

Source of income_____________
Health Insurance__________________
FINANCIAL ASSISTANCE NEEDS (Check all that apply):
I need help with the following cancer-related expenses:
Transportation: Child care Home care Pain medications
Lymphedema supplies Co-pays Other___________________________
Please itemize the actual cost and anticipated cost of all expenses below along with any receipts for
bills that have been paid, attach extra page if needed:_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Friends In Pink
Page Two
MEDICAL INFORMATION *** THIS SECTION MUST BE COMPLETED BY NURSE,
DOCTOR, SOCIAL WORKER OR HOSPITAL ACS PATIENT NAVIGATOR ONLY ***
Date of diagnosis: _____________ Primary cancer: ______________________ Stage ________
New diagnosis Recurrence Is patient in active treatment? Yes No
If not in active treatment, indicate frequency of follow-up: Yearly Every six months
Other_________
Please indicate type of treatment(s) received in past twelve months (check all that apply)
Chemotherapy Radiation Surgery Hormonal Other______________________
*** PLEASE COMPLETE ALL FIELDS ABOVE***
HEALTH CARE PROFESSIONAL INFORMATION (please print):
MD name: ____________________________________ Hospital/Clinic:
______________________________________
Address: ______________________________________________ City, State, Zip:
______________________________
Phone: ( ) __________________________ Fax: ( ) ___________________________
NAME AND TITLE OF PERSON COMPLETING THIS APPLICATION, IF
DIFFERENT THAN ABOVE (please print):
_______________________________________________________________________________
______________
Phone: ( ) ___________________________ Email:
________________________________________
Your relationship to person applying for help: Doctor Nurse Social Worker ACS
Hospital Patient Navigator
Signature of MEDICAL Professional: ______________________________ Date:
_____________ APPLICANT’S NAME: ___________________________________ DOB:
______________________
THIS SECTION TO BE COMPLETED BY THE PATIENT/PERSON REQUESTING
FINANCIAL ASSISTANCE:
Name of person completing this section (please print):
_____________________________________________________
Signature: ______________________________________ Date:
________________________________
Relationship to person applying for help: Self Spouse Family member/caregiver
Health care professional
Please be aware that funds are limited and based on availability. Patients must currently live in
19127 or 19128. Our grants are intended to assist with expenses and activities for daily living.
Incomplete applications cannot be processed.
Please return completed form, receipts and a copy of your government issued identification to
Friends In Pink
P.O. Box 35082
Philadelphia, Pa 19128
Questions? Feel free to contact us at 215-483-0592 or [email protected]