Internet Registration Form |
Please supply as much information as you can without breaking patient confidentiality. The appropriate literature will be posted to you. Information booklets will only be posted to addresses in the UK, the Republic of Ireland and British Forces (BFPO). |
| Required fields are in red* *Your E-mail: |
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*Your name:
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*Your address:
(UK and Republic of Ireland addresses only)
(literature will be posted to this address unless otherwise specified)
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*Your post code:
If you live in the Republic of Ireland, enter 'RoI'. |
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| *Your country: |
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| *Your telephone number: |
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| If you are the patient, check here: |
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| If you are not the patient |
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| Give patient's name: |
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| Patient's home address (if different to above): |
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| Patient's post code: |
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The following four fields are required for reasons of satistical analysis. Personal details will remain confidential. |
*Patient's date of birth:
If not known, give approximate year of birth |
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| *Hospital status: |
Not admitted
In-patient
Out-patient
Discharged |
*If patient is in hospital, which one? (Hospital/town):
If patient has been discharged, please enter the principal hospital where treatment was given.
If patient was not admitted, please enter 'not admitted'. |
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*Date entered hospital:
If not applicable, please enter 'not applicable'. |
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| Ward/unit: |
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| Ventilator status: |
Not applicable
Presently on ventilator
Was on ventilator
Ventilator not needed
Still too early to tell |
| Patient's relationship to you: |
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| Diagnosis: |
Guillain-Barré syndrome
CIDP
Miller Fisher syndrome
Other variant (state below)
Unsure
Not applicable |
| We have a Welfare Fund that may be able to offer financial assistance at difficult times. For example we can meet expences so you can visit a patient who is a long way from home in hospital. If you would like to receive details of the Welfare Fund, please check this box. |
Please send details of Welfare Fund |
If you would you like our local representative in your area to contact you, please check this box.
(He or she may be able to visit the patient in hospital) |
Please inform local representative |
| Other information: |
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| How did you get to hear about the Support Group: |
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| Any additional information on how you found out about us or a comment about the difficulty you had in finding us would be welcome so we might provide a better service. |
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| Send this form to: |
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| *Please enter the five figure verification code: |
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| If this form continuously fails to send, please register using our helpline. |
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