Service User Registration

If you are interested in whether we can assist you with one of our services, please fill in your details below and we will contact you.  Registration with us is not a guarantee that we can provide assistance.  Thank you.

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Name/ Contact Details

Title: Mr Mrs Miss

First name:  

Last name:  

Telephone:  

Email address:  

Confirm email:

Contact preference:

	Telephone
	Email

Address

Address line 1:  

Address line 2:

Town/ city:  

County:   Please Select Greater Manchester Lancashire Salford

Postcode:  

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Which location do you live in:   Please Select Barton Boothstown Broughton Cadishead Claremont Eccles Ellenbrook Irlam Irwell Riverside Kersal Langworthy Little Hulton Ordsall Pendlebury Seedley Swinton Walkden Weaste Winton Worsley Other

Other location: (please specify)

Doctor’s Details

Doctor’s surgery:  

Doctor’s name:

Doctor’s telephone number:

Doctor’s address line 1:

Doctor’s town/ city:

Doctor’s county: Please Select Greater Manchester Lancashire Salford

Doctor’s postcode:

Support Required

Befriending

Health Mentoring

Volunteer Driving

Any Other Requirements:

Medical Conditions

	Angina
	Asthma
	Chronic obstructive pulmonary disease (COPD)
	Coronary heart disease
	Heart attack
	Heart failure
	Lung cancer

	Lung disease
	Respiratory disease
	Sleep disorders
	Stroke
	Type 1 diabetes
	Type 2 diabetes
	Other

Other medical condition:

Additional info on medical condition:

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