Wessex MS Therapy information Form

Mr./Mrs./Ms./Dr. etc

First Name :

Last Name :

Address 1 :

Address 2:

Address 3:

Address 4:

Postcode :

Newsletter:

Yes / No

Advertising Rates:

Yes / No

Supporter Form:

Yes / No

Details of therapies available from the centre:

Yes / No

Help with supermarket collections:

Yes / No

Help in the MS charity shop:

Yes / No

How did you hear of Wessexms.co.uk? e.g. friend, search engine, other (please state).

Your email address:

Comments

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of this information via email?

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