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.............................................................................................