Health Professional Membership Form

Items marked with an asterisk (*) are required.

Contact details

Surname *

First Name *

Title

Job Title

Address

NHS Trust/Hospital you work for (if providing home address above)

Telephone

Fax

E-mail *

Secretary's Name

Secretary's Telephone

Secretary's Fax

Secretary's E-mail

Level of interest

How involved would you like to be?

Help with recruitment of patients

Yes	No

No direct involvement, but would like to be kept informed

Yes	No

Support trials and promot the Network in my area

Yes	No

** If you would like to get more involved, please list below the hospitals in your area which you would be able to cover.

Hospitals covered

Available resources

Does your department collect computerized diagnostic information?

Yes	No	Don't know

Comments

Area of Interest/Specialism - please state the skin conditions you have particular interest in

Clinical Trials Experience

Please tell us what experience you may have in developing and/or participating in clinical trials