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Self Management Course Register Form - Western Isles SMC

Register Form

Please fill in your details below.
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 provide your GP, Pain Clinic or Referrer with information on your attendance at the Association’s groups or courses.

· 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.

Please note that this sign up is for the Western Isles SMC online 5 week course. The course starts on Monday 19th October 2-4pm. The course will be in online via Zoom.
Signing up and providing us with your details means you are agreeing to be contacted by ourselves. Please note that we will email you with confirmation after we have received your sign up form.
1.Title(Required.)
2.Full Name(Required.)
3.Address(Required.)
4.Phone Number(Required.)
5.Email Address(Required.)
6.Date of Birth(Required.)
7.How did you find out about the course?(Required.)
8.Please give details of who referred you and their address if you know it(Required.)
9.Consent: If you are happy to be contacted by the Association if there is any issues with the course then please indicate below how you would like us to contact you(Required.)