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South West MS Centre Outreach Exercise Group at Tarka Leisure Centre

Client Details:

(all answers marked with an asterisk * are required)

Birthday
Day
Month
Year
Which type of Multiple Sclerosis do you have? (please tick)
What level of mobility do you have? (please tick)

DATA PROTECTION


Personal information about yourself will be kept securely, and we may be required to share information or contact other health professionals outside of the Centre to clarify details about your health. For more details, please see the section Confidentiality & Data Protection in the Members Centre User Guide.


If you would also like to hear about our services, appeals and ways you can support our work, we need your permission to do this. Please select all boxes relevant to you. If you do not select anything, we will not send information to you.

Consent to receive the following information:
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