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Required format:

pNHpiVdjNRZnKfrGpnYWoDoYwcWL9uEiWiq8P6ZHFUv5yGmZVI3cXi5UWTe

Consent to Contact Form

Please complete the survey below if you are interested in being contacted about potentially participating in a research study and/or joining as a PAC (Patient Advisory Committee) member.

Thank you!

Participating in a research study:

Each research study will have its own consent form and study-specific information provided. Completing this form does not indicate that you are a participant of a research study and is only for providing consent to our research team to contact you for research study purposes.

If you are 18 years of age or above and are interested in being contacted regarding the UBC Breast Reconstruction Program's breast cancer and/or reconstruction studies, you may be eligible to participate. Once you have completed this form, a member of the research team will reach out via email, phone or mail if you are eligible to participate in a research study.

Joining the PAC (Patient Advisory Committee):

Completing this form does not indiciate that you are a member of the PAC and is only for providing consent to our research team to contact you for PAC related purposes.

The Patient Advisory Committee (PAC) is a collaborative group with lived experiences, dedicated to enhancing breast reconstruction research and patient-researcher relationships. The PAC works closely with the research team to develop new topics, review ongoing studies, and find impactful ways to share findings with the public.

We are seeking individuals who have lived experiences with breast cancer care and/or breast reconstruction to join the PAC. Members meet via Zoom on the last Tuesday of every month at 6:00 PM for 1 hour. During these meetings, participants provide valuable feedback on projects and share their personal experiences to help improve research efforts and patient care.

Members are initially asked for a one-year commitment, aiming to attend 8-10 out of 12 meetings annually. Led by the UBC Breast Reconstruction Research Coordinator, these sessions feature discussions on current projects and personal stories from other committee members. This opportunity fosters a supportive community where members can connect and contribute meaningfully to breast reconstruction research.

If you have any questions about joining our Patient Advisory Committee or research studies as a potential participant, please feel free to contact us at research.plastics@ubc.ca by email, on Instagram @UBCBreastRecon, or at (604) 827-0438 by phone.

Please select which option you are interested and consent to be contacted by the research team about:

Participating in a research study

Participating as a PAC (Patient Advisory Committee) member

Both - participating in a research study and/or as a PAC (Patient Advisory Committee) member

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First Name

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Last Name

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Name of Plastic Surgeon

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If your plastic surgeon is note listed above, please enter it here:

Preferred phone number for contact

Preferred email address for contact

Mailing address for contact. Please complete if you would like to be contacted via mail

Please select ALL the times you would prefer to be contacted by phone call:

Weekday Mornings

Weekday Lunch

Weekday Afternoons

Weekday Evenings (after 5pm)

Weekend Mornings

Weekend Lunch

Weekend Afternoons

Weekend Evenings (after 5pm)

Other

Other specific times you would prefer to be contacted:

Privacy Notification

This is a confidential survey which will collect personal information such as your name and contact information. UBC is collecting this information under the authority of section 26(e) of the British Columbia Freedom of Information and Proection of Privacy Act (FIPPA). This information will only be used for contacting you regarding eligibility as a potential participant in a research study/studies and/or as a potential Patient Advisory Committee (PAC) member, depending on the boxes you have checked off above.

Please provide your signature:
Providing your signature signifies that you have thoroughly read the entirety of this form and consent to be contacted for research study and/or PAC purposes.

* must provide value

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.