Membership Application Form
Sign up now for you membership. It is free and will entitle you to receive our quarterly newsletter and to participate in our events. All that we ask is that you tell us a bit about yourself.

All information is held on a confidential database and will only be used internally and not given out to anyone.
Unfortunately we are unable to accept registrations from outside the UK but we are able to respond to emails sent from abroad.
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YES, please enrol me as a member of Ovacome. My contact details are
 Title
First name
 Surname
Address
Postcode
Telephone number
 Mobile number
Email address

 Can we pass on your details to our regional Ovacome co-ordinator?

 Yes
No
 If you are the person affected by Ovarian cancer and feel able we would be grateful if you could tell us a bit about yourself. This information is confidential to Ovacome and will not be shared with others without your permission.

 Date of birth

 Age at diagnosis

 Date when first diagnosed
   

 Have you any relatives with Ovarian Cancer?
 Yes No

 If 'Yes', who?

At what stage is is your disease? (If known) 
Stage 1 Stage 2 Stage 3 Stage 4 Unknown
   

 Treatments received, if any
 Surgery  Taxol/carboplatin  Carboplatin
 Cisplatin  Etoposide  Topotecan
 Caelyx  Radiotherapy  Other

 Is your treatment being given as part of a trial?
Yes No If yes - brief details

 How did you hear of Ovacome?

  

If you are a friend or family member of a patient, please indicate:
 Husband Partner Daughter Son
Mother Father  Friend  Other

 Are you are a healthcare professional

 Your position 
  Your hospital or place of work

 Some members like to distribute copies of the newsletters in GP surgeries etc. How many copies of the Ovacome newsletters would you like to receive each quarter?

  

  As a member, would you like to become more involved with Ovacome?
Yes, I am interested in
Fund raising Speaking to media
Speaking to other members Voluntary work with Ovacome
In some other way?  
 No not at the moment  

 Occasionally we send out simple surveys to our members. The information gained helps to represent patient views, but is confidential. Would you be happy to complete on of these.

  
Yes
No

 Would you like to receive email updates/news?
Yes
No
 Many thanks for your time completing this form. If you would like to speak to someone about any aspect of
Ovarian cancer please feel free to either phone us 020 7380 9589 Mon to Fri 9.00 am to 4.00 pm or
email us at ovacome@ovacome.org.uk. More information can be found at our website www.ovacome.org.uk


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©1998 OVACOME a voluntary organisation which relies on donations. Registered Charity Number 1058026.