Voice membership form

Name

First Last

Address

Street Address Address Line 2 City Postcode Country

Daytime telephone

Mobile phone

Email

How would you prefer to be contacted?

By email
By home telephone
By mobile

Can we say we are from the Macmillan Information and Support Centre and / or Voice if someone else answers the phone? (Due to confidentiality, our number will not be displayed.)

Yes
No

I am a:

Patient
Carer
Friend or relative

Level of contact

We have two levels of contact with Voice. Please tick which level is right for you. You can change this at any time.

Voice – plus contact: Receive the Cancer Connect newsletter twice a year by email + email updates about events for people affected by cancer + email information about patient partnership and engagement opportunities
Voice – standard contact: Receive the Cancer Connect newsletter twice a year by email

Consent

I give my consent for the information on this form to be kept on a database in the Macmillan Information and Support Centre at St George’s Hospital. This information will be confidential and will not be shared with any external organisation. I can ask for my details to be changed or removed at any time, without affecting my treatment or care.

I have ticked the box to confirm my consent

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