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Do you have a medical condition?
What is your primary reason for joining?

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. As part of becoming a member, we will send you the Annual Report and invitation to the Annual General Meeting, as this is a requirement. 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.

I am happy to receive the following information (tick all that apply)

Gift Aid - boost your donation by 25p for every £1 you donate
Gift Aid is reclaimed by the charity from the tax you pay for the current tax year. Your address is used to identify you as a current UK taxpayer.


I declare that I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year, it is my responsibility to pay any difference.

Please select an option:

Terms and Conditions

  • I give my consent to therapy assessment and treatment. I understand that all treatment options will be discussed and explained and their use will be my choice. By attending an appointment I understand that I am consenting to the treatment that I receive at that appointment.

  • ​I consent to all the applicable data protection boxes I have ticked within this form.

  • ​I consent to the applicable Gift Aid boxes ticked within this form.​

  • If I wish not to receive treatment as offered, I will make this clear to the therapist so that a note can be kept in my records.

  • ​I am aware that therapy may not benefit everyone and that it is not possible to know in advance if I will benefit. 

  • ​I agree to observe rules/protocols for therapy, the use of equipment and general use of the Centre, including for health and safety and efficiency.

  • ​I agree to advise the centre if there are any changes in my medical condition.

  • ​I understand that in order to provide appropriate care, it may be necessary for the therapist to contact other health care professionals such as my GP or specialist nurse, or to liaise with other therapists and staff at the Centre.

  • ​I acknowledge that the Centre accepts no liability for any injury caused by the use of any equipment, activity or therapy, other than in respect of injury resulting from the negligence of the Centre, or its employees and volunteers acting in the course of their duties for the Centre.

  • ​I give my consent for my personal data to be held securely at the Centre in line with General Data Protection Regulations.

  • ​I will respect the confidentiality and privacy of staff and other members.

  • ​I agree to become a member of the Multiple Sclerosis Therapy Centre South West Ltd and hereby guarantee to pay a sum not exceeding £1 in the event of the company being wound up.

How did you first hear about the Centre?

Thanks for registering. We will be in touch shortly.

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