EdgCARE Membership Application Form

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Thank you for applying for "Membership" status within the EdgCARE service. The person completing this form is considered the "Primary Member" and will be responsible for informing us of any updates to your details (address etc) and also payment.

1. Please enter your Full Name including any middle names: *

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2. Please indicate your gender: *

 

3. Please enter your full Postal Address: *

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4. Please enter your Date of Birth: *

   DD/MM/YYYY 
 
 

5. Please enter your Contact Details: *

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6. Please enter your Email Address: *

 

7. Please enter below the details of any other people residing at the above address who will be included in your Family Membership scheme

NameDOBContact NumberEmail Address
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5
Family Member 6
Family Member 7
Family Member 8
Family Member 9
 

8. Do you give your Consent for our service to communicate with you by email? *

 

9. Please tick to indicate which type of email communications you consent to receiving? *

 

10. Do you give your Consent for our service to communicate with you by SMS? *

 

11. Please enter details for your Next of Kin:

 

12. Are you registered with an NHS GP? *