Membership
Personal Details
Full name of child / adult with CMN:
Date of Birth:
Parents / Guardians full names (if applicable):
Full names of siblings and ages (if applicable):
Home address:
Home telephone number:
Email address:
How would you prefer to receive information from Caring Matters Now?:
Post
Email
CMN Details
Please state the location and size of the CMN:
Has the CMN been treated? (if 'yes' please state what treatments):
Is the CMN currently being treated? (if 'yes' please state what treatment):
Medical Details
Please state the names and addresses
of any Doctors you are registered with:
CMN Research Details
Are you registered with Dr Atherton's CMN clinic at Great Ormond Street Hospital?:
Yes
No
If you are not registered with Dr Atherton's CMN clinic, would you like to receive further details?:
Yes
No
Are you registered with the CMN research, which is taking place at Great Ormond Street Hospital?:
Yes
No
Would you be willing to participate in the CMN research at Great Ormond Street Hospital, if you are not already?:
Yes
No
