Membership Application

Please complete this form and press submit. We will confirm your membership by email. You will be required to to sign the form on your first visit.

Your name

Your email

Telephone No

Membership Status
—Please choose an option—PatientCarerOther

Your address

Date of Birth

GP name and address

Medical diagnosis

Medical restrictions

Please add any information we may need to know

I understand that a record of my medical condition and treatment received will be treated as strictly confidential in accordance with data protection and privacy laws
Please tick

I consent for my data can be shared amongst Hummingbird Cancer Support Group therapists
Please tick

I understand that treatments will be based on the information that I supply, and I consent to these treatments following consultation with the appropriate therapist
Please tick

This form will treated in confidence once submitted