How do you want to hear from us?

We want to contact you in a way you that suits you. Please use this form to tell us your preferences. You can change your mind at any time or choose to unsubscribe from all communication with us if you wish. If you have any questions about this form or about how we contact you please email mps@mpssociety.org.uk  or phone 0345 389 9901.

Please note that we need one form completed for every person who wishes to have contact with the MPS Society.


I would like to receive information about the services of the MPS Society, MPS events and conferences, information and updates on the work of the MPS Society, including the MPS magazine, in the following ways:
PostPhoneEmailFace to faceSMS, Messenger, WhatsApp


I would like to interact with the MPS Society’s Advocacy Support Team. I give my consent for them to contact me in the following ways:
PostPhoneEmailFace to faceSMS, Messenger, WhatsApp


I would like to receive information and updates regarding research, clinical trials, treatment and care options relevant to MPS, Fabry and related diseases, in the following ways:
PostPhoneEmailFace to faceSMS, Messenger, WhatsApp


I would like to receive information and contact from MPS Commercial in relation to clinical trial support and reimbursement, surveys and research, video interviews and Managed Access Agreements, in the following ways:
PostPhoneEmailFace to faceSMS, Messenger, WhatsApp


I do not wish to hear from the MPS Society or MPS Commercial
Please unsubscribe me from all communications

Your contact details
Children under the age of 16 may complete this form by themselves or a parent or guardian may complete it for them. We also need parent or guardian contact details for anyone under the age of 16. Please complete a separate form for everyone who wants to interact with the MPS Society.

Title

First name*

Surname*

Address line 1*

Address line 2

Address line 3

Postcode*

Country

Home phone number*

Mobile number

Email address*

What is your connection to the MPS Society*
Patient (please provide further details below)Parent/carerExtended familyDonor/FundraiserVolunteerHealth/Social Care ProfessionalScientist/ResearcherPharmaceutical Industry ProfessionalOther (Please describe)

Date of birth (if under 16 years)


Name of parent/guardian

Address (if different to above)

Main phone number

Email address

For person with a confirmed diagnosis of MPS, Fabry or a related disease only
If the above named has an MPS, Fabry or related disease please provide details below.
Date of Birth

Diagnosis

Diagnosing centre

Specialist centre

Treatment

Do you have any additional comments?

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We will always store your personal details securely. We will only use them to provide the service(s) that you have requested and communication with you in the way(s) you have agreed to. Your details may also be used for analysis purposes, to help us provide the best possible service. We will not pass on your details to anyone else and we will only share them if required to do so by law.