Register for the Next Clinic - PAWS-GIST UK Please complete the Registration Form below. Clinic Registration Form Please complete this Clinic Registration Form and then sign the Declaration below, giving your explicit permission for PAWS-GIST Clinic to process your information, thanks. Title First Name(s) Surname Email address Telephone Number Mobile Number Postal address City Post Code NHS Number Date Of Birth (DD-MM-YYYY) Age at Diagnosis Year Diagnosed Primary Tumour location GIST tumour type: Wildtype UnknownYESNO Hospital Oncologist Details: Oncologist Name Oncologist Email address Oncologist Telephone Number Can we contact your Oncologist? YESNO Surgeon Details: Surgeon Name Surgeon Email address Surgeon Telephone Number Can we contact your Surgeon? YESNO I am happy for my details to be shared with the Patient Director of the PAWS-GIST Clinic: YESNO DECLARATION I give consent for the PAWS-GIST Clinic to hold the above data concerning myself, (and as a patient I also give the PAWS-GIST Clinic my permission to retain any further personal data that I might supply which is relevant to my GIST journey and, if required, to use this anonymously in the furtherance of its mission). Declaration Signed By (name): Date Signed: Human test: Which is bigger, 2 or 8?
