Client Registration Form

Thank you for taking the time to complete this online form.
  • Date Format: MM slash DD slash YYYY
  • Medical Information

  • Date Format: DD slash MM slash YYYY
  • Treatment type you have received
  • 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.
Think Pink Foundation