Macmillan video call 1-2-1 information session request form

The information on this form will be kept confidential and not be shared with any external organisations. If you have any questions please speak to staff in the Macmillan Information and Support Centre on the ground floor of Grosvenor Wing, or call 020 8725 2677 or email cancer.information@stgeorges.nhs.uk. Please fill your details and preferred days and time for your session and we will invite you by email to the next available session.

First name:*

Last name:*

You are a:*

Patient
Carer

Preferred telephone number:*

Email*

Your session: (Please select your preferred days and times in the next five working days)*

Declaration*

I consent

I am a Social care or health care professional making a referral on behalf of the person named above. By ticking this box you confirm you have explained the Data Protection consent above and your patient has consented.

First Name*

Last Name*

Organisation*

Contact email*

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