National Tremor Foundation - Payment

Please complete the form below, print it out and then post it to us together with a cheque for £20.00 made payable to ‘The National Tremor Foundation’ to:

The National Tremor Foundation
Harold Wood Hospital (DSC)
Gubbins Lane
Romford
Essex. RM3 0BE

Title (tick one): Mr. Mrs. Miss. Ms. Dr. Other:

Name:

Address:

Post Code:

Telephone Number:

Email Address:

Date of Birth:

Type of Tremor:

Symptom Duration:

Consultants' Name:

Hospital:

Type of Membership (tick one): Patient Health Professional

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Title (tick one):	Mr. Mrs. Miss. Ms. Dr. Other:
Name:
Address:
Post Code:
Telephone Number:
Email Address:
Date of Birth:
Type of Tremor:
Symptom Duration:
Consultants' Name:
Hospital:
Type of Membership (tick one):	Patient Health Professional
	(If the above ‘Print this Page’ button does not work use your browser's print button on the tool at the top of the screen)