Teal Dignity Apparel | Comfort & Solidarity

Name

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Who is this item meant for?(Required)

Apparel Selection(Required)

Shirt Size

(Note: these shirts are handmade and run a little large)

Please confirm the Teal Dignity apparel recipient is in active treatment.

Teal Dignity apparel is intended for people currently undergoing treatment. To ensure the integrity of our program, we appreciate your confirmation.

Cancer Diagnosis

Stage/Grade

Diagnosis Date

Age at Diagnosis

Additional Information

Recipient Name

First Last

Recipient Address

Street Address Address Line 2 City State ZIP Code

Currently, we can only ship within the United States. Thank you for your understanding!

Recipient Email

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Recipient Phone

Your Name(Required)

First Last

Your Address

Street Address Address Line 2 City State ZIP Code

Currently, we can only ship within the United States. Thank you for your understanding!

Your Email(Required)

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Your Phone

Are you a gyn cancer survivor or active patient?(Required)

Cancer Diagnosis

Stage/Grade

Diagnosis Date

Age at Diagnosis

Additional Information

Would you like to send a note along with the shirt?

Inside the shirt flap, between the zippers, there’s a pocket for you to include a personalized note.

Message

Would you like the note to remain anonymous?

How did you hear about Teal Diva?

Internet Search

Referral from other organization

Friend or Family

Event or Conference

Social Media

Medical Provider

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Would you like to cover the cost of this shirt and/or future shirts?

Each infusion shirt costs $75. Gynecologic cancer patients receive them as a gift.

Infusion Shirt

Price:

Would you like to cover the cost of this beanie and/or future beanies?

Each beanie costs $35. Gynecologic cancer patients receive them as a gift.

Beanie

Price:

Custom Donation Amount

Total

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