Rare Disease Day - 28th February 2015

Membership

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

As a member of Caring Matters Now you will:

  • receive a copy of our six monthly newsletters
  • 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 state the location and size of the CMN *

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 your privacy seriously and will only use your personal information to create your personal profile, fulfil any requests from you and to help deliver and improve our services to you.

We promise to always keep your details safe and we will NEVER share or sell your details with unauthorised third parties. If you change your mind about hearing from us, you can stop receiving our updates at any time by emailing  info@caringmattersnow.co.uk  or calling 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): 
EmailPhoneTextPost

By clicking ‘submit’ you consent to us contacting you 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 including fundraising.