JOIN THE PATIENT ADVISORY PANELMost people complete this form in under 2 minutes What is your name? * First Name Last Name What is your DOB? * MM DD YYYY What is your sexual identity? Straight Gay Lesbian Bi-Sexual Pan-Sexual A-Sexual Quer Other Prefer not to disclose What is your gender? Female Male Non Binary Other Prefer not to disclose What is your ethnicity? Asian / Asian British - Indian Asian / Asian British - Pakistani Bangldeshi Chinese Other Black, Black British, Caribbean, African-Caribbean Black, Black British, Caribbean, African - African Black, Black British, Caribbean, African - Other Mixed or multiple ethnic groups - White and Black Caribbean Mixed or multiple ethnic groups - White and Black African Mixed or multiple ethnic groups - White and Asian Mixed or multiple ethnic groups - Other White - English, Welsh, Scottish, Northern Irish or British White - Irish White - Gypsy or Irish Traveler White - Roma White - Other Other Ethnic Group - Arab Which town or city do you live in? What is your postcode? What is your phone number? (###) ### #### What is your email address? * When were you diagnosed? MM DD YYYY What is your current treatment status? Newly Diagnosed In Treatment for Primary Breast Cancer Completed Treatment for Primary Breast Cancer Secondary Treatment Which hospital are you receiving care from? What treatments have you received for breast cancer? Chemotherapy Radiation Therapy Surgery Immunotherapy Treatment History Other (e.g. Trials) Have you been tested for the BRCA Gene? Yes No If Yes was your test Positive for BRCA Gene? Yes No Why would you like to participate in the Patient Advisory Group? How did you hear about us? Consent * I have read and accept the consent statement and am happy to join the Patient Advisory Panel. Yes Thank you!
