Evaluating a New Method for Breast Cancer Detection

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Required format:

r6vKuLCNp4hsouu6NqBVkn4GHZXZdH7VARsW86yWb4G5G

Thank you for your interest in the PINK research study.

To begin, please answer the confidential questions below to check your eligibility.

If you qualify, a team member will reach out with more information about the study.

This research is led by the Hennessy Institute at Hackensack Meridian Health, and all your information will be kept secure.

Do you reside in The Tri-state area?

* must provide value

Yes

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In the past 4 weeks, have you had a breast screening ?

Yes

I'm not sure

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When was your breast cancer screening done?

D-M-Y

Are you scheduled to have your annual breast screening soon?

* must provide value

Yes

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When is your cancer screening scheduled for?

* must provide value

D-M-Y

Do you have an upcoming biopsy scheduled ?

* must provide value

Yes

I had one already

I'm not sure

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When is your biopsy scheduled for?

* must provide value

D-M-Y

Is the healthcare provider who provided you with the order/referral, or the screening facility part of Hackensack Meridian Health (HMH)?

* must provide value

Yes

I am not sure

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We're happy to help you with that. If you're unsure whether your provider or screening facility is part of Hackensack Meridian Health (HMH), simply let us know their name, and we will check for you.

What is your age?

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Younger than 18

18 to 39

40 to 79

80 and above

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In the past 2 weeks, have you had any medical procedures involving your chest or airways?

* must provide value

Yes

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In the past year, have you been diagnosed with or received treatment for cancer?

* must provide value

Yes

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What is your biological sex (how you were born)?

* must provide value

Female

Male

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Have you had surgery to remove your breasts?

* must provide value

Yes

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Do you have hereditary genetic mutation that increases your breast cancer risk?

Yes

I don't know

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Please select the genetic mutation you carry:

BRCA1

BRCA2

PTEN

TP53

CDH1

STK11

ATM

CHEK2

BARD1

RAD51D

RAD51C

PALB2

Other

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Do you have a family history of breast or ovarian cancer diagnosed before age 50?

Yes

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Please provide your contact information below, so we can reach out to you regarding next steps;

Name (first and last):

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Email Address:

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Phone Number:

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