I want to share my contact information with the Gene Machine

Please describe the event:*

What type of group?*

Select or enter value

Please describe the group:*

I have a history of breast cancer.*

Yes

No

I was diagnosed with breast cancer when I was:*

Select

My race is:*

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One or more of these statemenst are true:*

Please choose all that apply

I have one or more blood relatives with cancer.

I have been diagnosed with breast cancer more than one time.

I'm the only one with cancer in my family.

Unknown

I have blood relatives (grandparents, parents, children, siblings, aunts/uncles, nieces/nephews, or first cousins) with one or more of these cancers:*

Choose all that apply

Other cancers in my family are:

Please list other family cancers