SEPTRIN*
INFORMATION
(Also
Bactrim and co-trimoxazole)
If
you wish to do so, please complete this
form and return it as soon as possible
to: Brian Deer, xx xxxxxxxxx, xxxxxx xxx
xxx.
1.
List (a). I would like my name,
address and telephone number to be made
available, with those of others, to any
doctors or journalists who wish to
investigate our problems. I understand
that no confidentiality will be
preserved.
- FOR
"NO": LEAVE BLANK
- FOR
"YES": SIGN
HERE.......................................................................
2.
List (b). I would like to be kept in
touch with any future developments. I
understand that my details may be given
to those persons organising any meeting
or preparing any subsequent
corespondence.
- FOR
"NO": LEAVE BLANK
- FOR
"YES": SIGN
HERE......................................................................
3.
Meeting. I would like to meet with
other people who believe that their
health has been affected by this drug.
YES/NO
(Please delete as appropriate)
4.
Organising. I would be willing to help
with organising any meeting.
YES/NO
(Please delete as appropriate)
NAME.........................................................................................................
.....................................................................................................................
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TELEPHONE.............................................................................................