Community Wellness Support | Center Peace Wellnes

CenterPeace Wellness is proud to partner with GoJenGo to help make wellness services more accessible to breast cancer patients. Please complete the application form below to request assistance. Eligibility and program availability apply.

Last name

Phone

Birthdate

Month

Day

Year

Breast Cancer Type/ Subtype and Stage

Name of Oncologist/Physician

May we contact your Physician, Social Worker, or Patient Navigator on your behalf?

Yes

List the name of your Social Worker or Patient Navigator.

Please share any symptoms or concerns you are experiencing related to swelling, lymphedema, or changes in your affected area(s) such as: (Location of swelling - Any pain, heaviness, tightness or skin changes - Previous treatments or evaluations)

I authorize the release of medical information and documentation through email, fax or telephone communication(s) required by CenterPeace, PLLC to verify and determine eligibility for assistance as a GoJenGo-approved grantee.

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Signature

Date

GoJenGo-approved Grantees will receive one consultation visit with Manual Lymphatic Drainage (MLD) at no cost through the CenterPeace Wellness Community Partner Program. This visit is designed to provide education and guidance related to lymphatic care.