Metabolism and Weight Management Forum - Thorpewood Positive Health Initiative

Registration

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* 1. Are you registered as a patient at Thorpewood Medical Group?

Yes

No

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* 2. Please enter your contact information below

First name

Surname

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 3. What is your sex?

Male

Female

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* 4. Please enter your date of birth

Date / Time

Date

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* 5. Does the above mentioned agree to consent for the handling and storage of information generated as a result of participation in the programme?

Yes

No