Regional Mtg - Members Registration Form

'Virtual' Regional Meeting 12 May 2023

hosted by Professor Marianne Nicolson, Consultant Medical Oncologist, Raigmore Hospital, Inverness

Non-Members Registration Form - Early Bird

Name

Email*

Phone Number

Job Title

Name of Hospital

Name of Trust

Place of Work or Hospital & Trust if not listed above

Work Address Line 1

Work Address Line 2

Work Address Line 3

Town

Postcode

Region

Are you happy for our pharmaceutical sponsors to contact you during the meeting?

Are you happy for us to keep in touch via email regarding news about the charity, such as our quarterly newsletters?

Please select your payment

Please enter your card details below

Card Number*

Expires*

Security Code*

When you press Donate we will take to you a secure form to enter your bank account details

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£45