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· Your Voice In Health and Social Care in Northern Ireland ·

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The information you provide us will be treated in confidence and stored in compliance with the Data Protection Act.

The Patient and Client Council will never share your information with a third party without your prior consent.

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1. Personal Details

Day: Month: Year:
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2. Contact Methods

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3. Membership type

(Go to question 5)

(Please fill in Question 4 below)

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4. Organisation / Group Details

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5. Your interest

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6. Access Requirements

We assure you that the information you provide will be treated confidentially.
Thank you for completing this form.