Rare Disease Day - 28th February 2015

Membership

Fill out the form below to become a member today. Membership is FREE.

A member is an adult with CMN or a parent of a child with CMN.

As a member of Caring Matters Now you will:

  • receive a copy of our annual magazine
  • get invited to Caring Matters Now support and fundraising events
  • connect with other families
Patient Details

Patient Title *

Patient Forename *

Patient Surname *

Patient Date of Birth *

Patient Nationality *

Patient Contact Details

House Name

House Number *

Address 1 *

Address 2

Town *

County *

Country *

Postcode *

Is the patient an adult? *

Email Address *

Landline Number *

Mobile Number *

Do you have any siblings? *

Parent/Carer/Husband/Partner Details

Parent/Carer Title *

Parent/Carer Forename *

Parent/Carer Surname *

Relationship To Patient *

Please state your relationship to the patient *

Parent/Carer Email Address *

Parent/Carer Landline Number *

Parent/Carer Mobile Number *

Would you like to add details of another Parent/Carer? *

Parent/Carer 2 Title *

Parent/Carer 2 Forename *

Parent/Carer 2 Surname *

Relationship To Patient *

Please state your relationship to the patient *

Parent/Carer 2 Email Address *

Parent/Carer 2 Landline Number *

Parent/Carer 2 Mobile Number *

Other Details

How did you hear about us? *

CMN Details

Please tick the area(s) of the body where the bulk of the CMN is located: *
ScalpFacialArmBoth ArmsHandBoth HandsShoulderMain TrunkBackChestStomachLegBoth LegsNumerous CMN (smaller CMN on various or all parts of the body)

Have any additional problems been diagnosed? *

If yes, please provide brief details:

Has the CMN been treated? *

Please state what treatments

Medical Details

Is the patient under the care of a local consultant? *

Please state the name of the local consultant and hospital you are registered with *

CMN Clinic and Research Details

Are you registered with the CMN clinic at Great Ormond Street Hospital? *
YesNo

If you are not registered with the CMN clinic, would you like to receive further details? *
YesNo

Are you registered with the CMN research, which is taking place at Great Ormond Street Hospital? *
YesNo

Would you be willing to participate in the CMN research at Great Ormond Street Hospital, if you are not already? *
YesNo

Data Protection Policy

Here at Caring Matters Now we take yours and your family's privacy seriously and will only use the personal information you provide on this registration form to create a personal profile, fulfil any requests from you and to help deliver and improve our services to you and your family.

We promise to always keep the details you provide safe and we will NEVER share or sell the details you provide with unauthorised third parties. If anyone whose details have been provided to Caring Matters Now wishes to be removed from the communication list, please email info@caringmattersnow.co.uk  or call 07786 458883.  Please see our Data Protection Policy for more information. 

To receive the best support and services we recommend you select all the contact options below. 

Please contact me by (please tick): 
EmailPhoneTextPostNo contact

By clicking ‘submit’ you consent to us contacting you and those you have detailed on the form about our services and ways you can help, including ways to volunteer, take part in research, donate to us and how you can get involved in our activities.