Members Details - Person with CMN
Members Title *
Members Forename *
Members Surname *
Members Gender *
Members Date of Birth *
Is the member under 18? *
Members Address
House Name
House Number *
Address 1 *
Address 2
Town *
County *
Country *
Postcode *
Other Details
Which race/ethnicity best describes you and your family? *
Asian/Asian British - (Indian, Pakistani, Bangladeshi or Any other Asian background)Black, Black British, Caribbean or African - (Caribbean, Arican or Any other Black, Black British, or Caribbean background)Mixed or multiple ethnic groups - (White and Black Caribbean, White and Black African, White and Asian or Any other Mixed or multiple ethnic background)White - (English, Welsh, Scottish, Northern Irish or British, Irish, Gypsy or Irish Traveller, Roma or Any other White background)Other ethnic group - (Arab or Any other ethnic group)Rather not sayAnother race or ethnicity (please specify)None of the above
Members Nationality *
Members Native Language *
If you are likely to attend any of our events in the future, please make us aware of any additional information which would be relevant to planning events which are accessible for your family. For example: if anyone in your family has any accessibility or communication needs. Please detail below: *
How did you hear about us? *
CMN Details
Please tick the area(s) of the body where the bulk of the CMN is located: *
ScalpFacialRight ArmLeft ArmBoth ArmsRight HandLeft HandBoth HandsShoulderMain TrunkBackChestStomachRight LegLeft LegBoth LegsNumerous CMN (smaller CMN on various or all parts of the body)
Any additional medical complications in relations to CMN? *
Has the CMN been treated? *
Medical Details
Is the member 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