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Tell Your Story

You could help to raise awareness of breast cancer by sharing your story with the media. Real-life stories such as yours are vital in inspiring others, highlighting issues and encouraging people to fundraise for Breakthrough Breast Cancer. We will always make sure you are happy to take part in any media interviews and we will never pass on your details without your consent.

denotes mandatory fields.

Title:

First Name:

Last Name:

Gender:

male female

Address 1:

Address 2:

Address 3:

Town/City:

County

Country

Postcode

Telephone (day):

Telephone (evening):

Email:

Date of Birth:

Occupation:

Do you have any children?

Yes No

Ages:

Do you have any grandchildren?

Yes No

Ages:

Have you had breast cancer?

Yes No

Date Diagnosed:

Age when diagnosed:

Do you have family or friends with breast cancer?

Yes No

Please give details:

Whether you, a friend or a member of your family has had breast cancer, please tell us as much as you can about your experiences. If possible, please give details about: Your ups and downs, what you've changed, what you want to tell others; any significant achievements or extraordinary experiences; Any fundraising you have done or are planning to do. Please also include any other information that you feel is important and attach extra pages if necessary.

How was your cancer diagnosed?

I noticed a change to my breast My partner noticed a change to my breast Through the NHS Breast Screening Programme

If you or your partner noticed a change to your breast, was it any of the following symptoms?

At what stage was your breast cancer?

Early stage breast cancer Secondary/Advanced breast cancer

Please tick the treatments you have received. Tick all that apply:

Other (please state):

Have you received treatment for lymphoedema?

Yes No

If yes, please give details:

Have you or any members of your family had genetic testing?

Yes No

If yes, please give details:

Do you have any other involvement with Breakthrough Breast Cancer?

Please give details:

I agree to Breakthrough Breast Cancer keeping and using this information for the purpose of promoting Breakthrough and the cause of breast cancer through the media and other relating occasions. I understand Breakthrough will not give out my details without my verbal and/or written consent on each occasion (Data Protection Act 1998)

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Tell Your Story

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Tell Your Story

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Be Inspired

Email Updates

Big Pink Shop