CCSG Online Membership Form

(printable)

Today's date ________________

SECTION 1

Ms
Mr
Mrs
Miss ____________________________________________________________________
Dr

Address __________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Telephone _______________________ (home) ___________________________(business)

Email ___________________________________ Fax _____________________________

Occupation ________________________________ Date of Birth ____________________

Do you have CROHN'S DISEASE or ULCERATIVE COLITIS?____________________

or are you: RELATIVE, FRIEND, HEALTH PROFESSIONAL, COMPANY? ________

How did you find out about the CCSG? _________________________________________

Are you willing to participate in medical research? (NZ only) . . . . . . . . . . . . . . . . YES / NO

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SECTION 2

Please supply the following information for our specialist database.

Your specialists name _______________________________________________

At what clinic/hospital do they work? ________________________(eg. Auckland Hospital)

________________________________________________________________(town/city)

Would you recommend your specialist to another patient? . . . . . . . . . . . . . . . . . . YES / NO

Other comments about your specialist __________________________________________

_________________________________________________________________________

_________________________________________________________________________

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SECTION 3

Privacy Act 1993: Please check the box if you DO NOT want your details (name, ph. no.) to be passed on to other members, or appropriate people or organisations. The CCSG will not sell or pass on its complete mailing list. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Please complete the membership form and return with your subscription* to:

CCSG Inc.
PO Box 24171
Royal Oak
Auckland
New Zealand

* Annual Subscription NZ$30.00 incl. GST. Make all cheques payable to CCSG Inc.

* For international members please see notes about payment on the Membership page

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