Familial Breast Cancer Research Unit Self-Referral Form

The Familial Breast Cancer Research Unit (FBCRU) at Women's College Hospital (WCH) is led by Dr. Steven Narod (Tier 1 Canada Research Chair), Dr. Kelly Metcalfe, Dr. Joanne Kotsopoulos, and Dr. Mohammad Akbari. The FBCRU is internationally renowned for identifying and developing effective strategies to prevent and manage hereditary cancers in women and families with a high inherited risk. All research studies have been approved by the WCH Research Ethics Board.

If you are interested in hearing about how you can participate in our research studies, please provide us with your contact information. By completing this form, you are consenting to being contacted by a member of the FBCRU team to learn more about our research studies. Any of your personal information collected or obtained, whether you choose to participate or not, will be kept confidential and protected to the fullest extent of the law. All personal information collected will be kept in a secure location. The risks of a privacy breach are minimized as much as possible, but confidentiality cannot be fully guaranteed. After speaking with our team, you will have the opportunity to consent and participate in a research study.

First Name

* must provide value

Last Name

* must provide value

How would you like to be contacted?

Phone

Both

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* must provide value

Phone Number

* must provide value

To help us better understand what studies you may be eligible for, please provide us with more information:

Do you have a cancer diagnosis?

Yes

Prefer not to answer

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What cancer(s) have you been diagnosed with?

Have you undergone genetic testing and found to have a mutation?

Yes

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What gene(s) were found to have a positive mutation?

If you are interested in a specific research study, please let us know in the comment section below:

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Thank you for your interest in our research! To learn more about ongoing research initiatives at the Familial Breast Cancer Research Unit, please visit our website here.

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