Wilson's Disease Support Group - UK MEMBERSHIP FORM Our regularly updated mailing list and database enable us to keep record of very important data. We will be able to keep track of you so that : * We can keep you informed about new drugs, new side effects to drugs, and developments regarding Wilson's Disease * We can keep track of relatives to keep them informed and be sure they are properly screened to promote early diagnosis and treatment * We can keep track of people with a special interest in the disease * We can keep track of organisations and research centres interested in the disease and keep them aware of the association In order to accomplish these goals, we need you to carefully complete this application form and send it along with your dues, which are owed each calendar year. This pays for the newsletter, postage, printing.. Wilson' Disease Support Group UK is an all-volunteer association and no one is paid for any service to the group. Surname: ............................................................ Maiden Name (if applicable): ........................................ First Name (s): ..................................................... Sex: ................ Age:.............. Address: ............................................................ ...................................................... County: ............................................................. Postcode: .......................................... Home Phone: ......................................................... Work phone: ......................................................... E.mail Address: ..................................................... Relationship to Wilson's Disease (circle) : patient, parent, grandparent, sibling, child, aunt, uncle, cousin, friend, grandchild, other (please state) ................................................ For Patients Birthdate: ............................................. Treatment: (circle) penicillamine, trientine, zinc, tetrathiomolybdate, other (please specify) ............... Initial Symptoms: ................................................... ................................................................... ................................................................... ................................................................... ................................................................... ................................................................... Diagnosis Date : .................................................... Hospital diagnosed :................................................. Initial treatment : ................................................. ................................................................... ................................................................... ................................................................... ................................................................... Other treatments / hospital treatments / complications: ............. ................................................................... ................................................................... ................................................................... ................................................................... If you are unable to pay dues, please send back your completed form. Any amount, regardless of how small helps. Details: Annual basic membership fee £ 5 (Cheques made payable to: Wilson's Disease Support Group - UK) Please send completed form and dues to: Linda Hart 36 Audley Drive Lenton Abbey Beeston Nottingham NG9 2SF Would you like your name placed on a list with others willing to give each other support by writing, calling or meeting ? (circle one): Yes / No A line about confidentiality Any other information given on this sheet will be treated with strictest confidence !!!