Medical Provider Form | Knitted Knockers

By completing the registration form below we will send you materials for your office. If you have already registered, please use this form to let us know what you need and/or how we can help you.

Is this clinic registering for the first time?*
Clinic Name*
(Please do not use acronyms. Spell out full clinic name.)
Contact Name*
First Last
Contact Title
Country*
Shipping Address*
(include street address and suite/unit number as needed)
City*
State*
State / Province*
Zip / Postal Code*
You have reached Knittedknockers.org located in the US. While we fill orders all over the world I am sure you wanted to reach the wonderful group in the UK. They can be reached via their website, http://www.knittedknockersuk.com/.
You have reached Knittedknockers.org located in the US. While we fill orders all over the world I am sure you wanted to reach the wonderful group in the Australia. They can be reached via their website, http://knittedknockersaustralia.com/.
Email*

Please add barbara@knittedknockers.org, medical@knittedknockers.org and knittedknockers@gmail.com as “not junk” in your mailbox. If you do not receive a confirmation email immediately your filters have removed our email and we will not be able to communicate with you. A personal email may be required.
Phone*
Website
Best way to contact you?*
- Email
- Phone
How did you hear about us?
Have you already received brochures and sample knockers for patients?*
- No
- Yes
Do you have a group to supply you with Knockers?*
Please encourage your group to register with us as a knitter/crocheter at knittedknockers.org and mention they are supporting you. We want to equip them to use approved yarns and share ways we can help support them.
We will look for a local group to provide directly to you. If you have a group that may consider knitting for you encourage them to register as a knitter/crocheter with us and we will equip them to provide for you.
Contact name of group supplying you with Knockers
How many brochures?
How many business cards?
How many Care Instructions?
To be included with knockers given out.
Use the text box below to reorder materials (such as brochures, care instructions, or business cards) or to ask us a question.
How can we help you?
Knitted Knockers Support Foundation is a 501(c)3 run 100% by volunteers. We survive strictly by donations. We are thrilled to partner with medical clinics to provide free knitted knockers to their patients. For those that have the resources to help us out with costs though it is really appreciated. The cost of providing materials to a clinic runs us about $200 a year. Any donations are sincerely appreciated. Do NOT let that stop you from partnering with us though. We want to help reach out to your women that can use them. More information can be found on our Make a Donation page.
Terms of Use*
Check the box below to acknowledge and accept our Terms of Service and our Privacy Policy.
- I accept the Terms of Use and Privacy Policy of KnittedKnockers.org and to my submitted data being collected and stored.