Screen Reader Mode Icon

Register Form

Please fill in your details below. 
 
Signing up and providing us with your details means you are agreeing to be contacted by ourselves.
Pain Association Scotland takes your privacy seriously and will only use your personal information:

·      To provide you with information on the Association’s services.

·      To provide your GP, Pain Clinic or Referrer with information on your attendance at the Association’s groups or courses.

·      To improve our service and to contribute to research into chronic pain.
 
Under GDPR the details are for our records and therefore won’t be shared with anyone else.
 
A full copy of the policy can be found on our website.
 
* PLEASE NOTE THAT WE WILL EMAIL YOU ONCE WE HAVE RECEIVED YOUR SIGN UP. SO PLEASE CHECK YOUR JUNK INBOX*
 
 
*PLEASE NOTE THAT YOU HAVE TO LIVE IN THE HEALTH BOARD TO ATTEND THE MEETINGS*

Question Title

* 1. Please select a group from the drop down menu in the next question. Please note that some group meetings are online only and some are a blended model of face to face and online.

*PLEASE NOTE THAT YOU HAVE TO LIVE IN THE HEALTH BOARD TO ATTEND THE MEETINGS*

Signing up and providing us with your details means you are agreeing to be contacted by ourselves.

Question Title

* 2. Which group will you attend?

Question Title

* 3. Title

Question Title

* 4. Full Name

Question Title

* 5. Address

Question Title

* 6. Phone Number

Question Title

* 7. Email Address

Question Title

* 8. Date of Birth

Question Title

* 9. Who were you referred by

Question Title

* 10. Please give details of who referred you and their address if you know it.

Question Title

* 11. Consent: If you are happy to be contacted by us for future communications which may be of interest to you please select from the following list your preferred method of contact.

0 of 11 answered
 

T