pelvicpartnership.org.uk

Forename: *

Surname: *

Date *

Address *

Postcode *

Telephone number *

Email address *

Confirm Email address *

Donation value *

Name (if different from above) *

Date of birth *

Is this information for you? Yes No

If not, who is it for? Friend Relative Patient

How long have you had pelvic pain and when did it develop?

Are you pregnant at the moment? yes no

Is the pain related to pregnancy? Yes No

How many children do you have and in which years were they born?

Did you have pelvic pain with each pregnancy? Yes No

Do you still have pain now? Yes No

How would you rate the severity of your pain? 1 2 3 4 5 6 7 8 9 10

Have you had any treatment, from whom and how effective has it been?

Have you found any information from other sources, and, if so, what were they?

Please add any extra information you would like to share in this section

Would you like one of our volunteers to call you regarding your comments? Yes No

Would you be happy for us to print your story in our newsletter or website? Yes No

How did you find out about the Pelvic Partnership? Friend Flyer in GP surgery / Hospital Magazine Article Pregnancy / Birth book Internet Midwife Physiotherapist GP Other

I would like the Pelvic Partnership to treat all donations I have made since 6th April 2003 and all the donations I make from the date of this Declaration until I notify you otherwise as Gift Aid donations. I have paid an amount of income tax and/or capital gains tax at least equal to the tax that the charity will reclaim on my donation. (NB if the Pelvic Partnership's claim is more than the tax paid by the donor, the donor will have to pay the difference to HMRC). I understand that I can cancel this Declaration at any time by notifying the Pelvic Partnership. If my circumstances change and I no longer pay tax, or if I change my address, I will inform the Pelvic Partnership. Yes No *