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Leeds Group Register Form

Register Form

Please fill in your details below.

Signing up and providing us with your details means you are agreeing to be contacted by ourselves.
Pain Association Scotland takes your privacy seriously and will only use your personal information:

· To provide you with information on the Association’s services.

· To improve our service and to contribute to research into chronic pain.

Under GDPR the details are for our records and therefore won’t be shared with anyone else.

A full copy of the policy can be found on our website.

1.Title(Required.)
2.Full Name(Required.)
3.Address(Required.)
4.Phone Number(Required.)
5.Email Address(Required.)
6.Date of Birth(Required.)
7.Who were you referred by(Required.)
8.Please give details of who referred you and their address if you know it.(Required.)
9.Do you require any specific access needs or disabled parking(Required.)
10.Please tick if you wish to attend in person or online viaZoom(Required.)
11.If there is an issue with the meeting and we need to let you know, please select your preferred method of contact.(Required.)
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