How to request a Chemogiftbag

Would you like to request a Chemogiftbag for you or a loved one?

Please complete the attached pro-forma and once we have received your request we will contact you. Our Ambassador for your area will agree a date and time to meet, usually before your hospital appointment.

We ask that you arrive approximately 15 minutes before your appointment and have your mobile phone with you and turned on.

Please note:

If for any reason you need to cancel or change your meeting with our Ambassador, please call them as soon as you can. Another meeting can be arranged for you.

Apply for a Chemogiftbag

Please complete the whole pro-forma.

Before you do this, you must make sure that the recipient of the bag, if not you, has given their permission for you to provide us with their details so that our Ambassador can contact them to arrange receipt of a Chemogiftbag.

Your full name

Your email address

Please advise if you/they have breast cancer and are undergoing chemotherapy

Please note: We can only arrange for Chemogiftbags for people being treated in the below approved list of hospitals.

Which hospital is treatment being received at?

Full name of the recipient?

Which bag type would you like?

Recipient Phone / Mobile Number

What is the recipients address?

Recipients phone number?

Date of next hospital appointment

Time of hospital appointment

Name of hospital where treatment is

Permission to contact the recipient

Please tick yes to confirm if we have permission for Chemogiftbags’ to contact the person who will be the recipient the bag.

Confirm you are based in UK

I confirm that I understand that Chemogiftbags are only available in the UK and that I am based in the UK.

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How to request a Chemogiftbag

Apply for a Chemogiftbag

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