New Client Registration Form

Thank you for taking the time to complete this online form

Name*First NameLast NameEmail*Phone*Format 0400 123 123 or 03 1234 5678Date of Birth*
Address*Address Line 1Address Line 2

City/Suburb

State / Territory

Postcode

Country

Emergency Contact Name*

First Name

Last Name

Your Relationship to Emergency Contact*

Emergency Contact Phone Number*

Format 0400 123 123 or 03 1234 5678

How did you hear about Think Pink?* (Press Ctrl+key to select multiple options)

Have you had contact with a Breast Care Nurse at your treatment facility? If so, please provide further details*

Medical Information

Diagnosis*

Date of Diagnosis*

Treating Doctor/Surgeon
Treating Hospital*
Treatment Type (Press Ctrl+key to select multiple options)*

Other-Medical Conditions

Dietary Restrictions

Which programs or services are you interested in? (First Select Breast Care Nurse Consult, then press Ctrl+key to select multiple options)

The Living Centre Programs Waiver and Release

The Think Pink Living Centre (“Living Centre”) is an independent, non-clinical facility dedicated to providing emotional, psychological, practical and physical support for those diagnosed with breast cancer. We welcome all clients affected by breast cancer, including men and women, families, partners and carers. The focus at the Living Centre is wellness not illness. This Waiver and Release form acknowledges our role in engaging external providers (“External Providers”) to provide services and run programs, free of charge, at our Living Centre. This form has been prepared for the purpose of ensuring that use of the Foundation’s facilities and its Living Centre is undertaken at your own risk, and that you take full responsibility for any injury that you may sustain whilst on the premises or using the facility or it’s equipment, whether caused by yourself or by another. Whilst the Think Pink Foundation (“Foundation”) and its Living Centre provide counselling of a general nature and may raise awareness of various treatment options available to clients, they are not licensed or registered medical providers, nor do they make any treatment recommendations. The Foundation and its Living Centre stipulate that you speak to a health professional treatment team to obtain detailed information to help you make a final decision regarding the treatments available.

Client Permission*
I have read the waiver and release information outlined above and agree to waive any right to pursue any claim as a result of my participation in any of the programs or any information that I receive from staff, volunteers or other clients.

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