Shop Well With You

To receive individualized assistance from SWY's personal shopper, please fill out this Resource Request Form. We will respond shortly with information and resources to address your specific request.

All information submitted will be kept confidential. Information marked with an asterisk (*) is required. All other questions are optional although the more information you provide, the better we can assist you.

Resource Request Form

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Phone Number: *

(212-555-5555)

Fax:

Email Address:

Detailed Description of your Request:
(What are you looking for? What are your particular needs?) *

How did you hear about Shop Well With You?

Brochure
From a friend
Hospital
Support group

Magazine/Newspaper
Health Practioner
Other

What kind of cancer did/do you have? Are you currently in treatment? *

Did you have reconstructive surgery? Yes No

If yes, please explain:

Where can you shop? *

Online Catalog Stores

Please fill in boxes applicable to your request:

Age:
Height:
Weight:

Bra Size (when applicable):
Pant Size:
Blouse Size:
Dress Size:

Price Range:

Please note that we will provide you with resources from your chosen price point and below.

How would you prefer to receive the response to your request? *
Email Mail Fax Other:

Describe your personal style (conservative, ethnic, sporty, funky, chic):

Is there anything you are not comfortable wearing as a result of surgery
or treatment? Are there any specific requirements for your clothing?

Is there any additional information you would like to add?



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