UNITED NORWICH KIDNEY PATIENTS ASSOCIATION

UNKPA MEMBERSHIP FORM

Registered Charity 29467/R

Affiliated to the National Kidney Fund

Patient Name:
Address:

Post code:
Telephone:

Signature:

Carer / other address:
Address:

Post code:
Telephone:

Signature:

 
I understand and agree to the above information being held on record by U.N.K.P.A. and I undertake to inform U.N.K.P.A. of any change to the above details.
 
I would like / not like my details sent to the National Kidney Fund, to receive copies of Kidney Live Magazine.
 
Please complete and return this form to:
 
U.N.K.P.A.
Jack Pryor Unit
Norfolk & Norwich NHS Trust
Colney Lane
Norwich
NR4 7UY