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Charity Commission 1199955
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.
—Please choose an option—PatientCarerOther
Date of Birth
GP name and address
How did you hear of us?
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
I consent for my data can be shared amongst Hummingbird Cancer Support Group therapists
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
This form will treated in confidence once submitted
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