Veterans Group Register Form -

Please fill in the questions below with your details.

Pain Association Scotland takes your privacy seriously and will only use your personal information:

· To provide you with information on the Association’s services.

· To provide your GP, Pain Clinic or Referrer with information on your attendance at the Association’s groups or courses.

· To improve our service and to contribute to research into chronic pain.

Under GDPR the details are for our records and therefore won’t be shared with anyone else.

A full copy of the policy can be found on our website.

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* 1. Title

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* 2. Full Name

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* 3. Address

Address

Address 2

City/Town

Postcode

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* 4. Phone Number

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* 5. Email Address

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* 6. Date of Birth

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* 7. Armed Forces Number

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* 8. Unit

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* 9. Rank

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* 10. Discharge Date

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* 11. Who were you referred by

GP

Hospital

Psychologist

Physiotherapist

Pain Clinic

Pain Management Programme

Self - Refer

Other (please specify)

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* 12. Please give details of who referred you and their address

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* 13. Consent: If you are happy to be contacted by the Association then please indicate below how you would like us to contact you

Landline

Mobile

Email

Not Granted