PINC & STEEL Registration Patient Details Please tick the box that applies to you: I want to register for individual sessions. I am ONLY interested in attending group programmes (Targeted Class, Next Steps, PaddleOn, Online class) and do not wish to register for individual sessions. I am interested in both individual sessions and group programmes. Please complete the registration form below to be connected to your local certified PINC & STEEL Oncology Physiotherapist. Please select the relevant box: I can self-fund the initial assessment cost I need funding assistance for the initial assessment First Name Last Name Email Address Phone Number Gender Gender Female Male Don't know Prefer not to say Age Select your age Under 20 20-39 40-59 60-70 70-80 80+ Ethnicity Select your ethnicity British Irish Scottish Black Mixed Other (Please state) Street Address Address Line 2 (Optional) Suburb City Region Select the region nearest to you Buckinghamshire East England - Essex / Kent East Midlands East of England-Suffolk Ireland London North West North Yorkshire Northern Ireland Scotland South Coast South East of England South West South Yorkshire Stour Bridge Wales West Midlands West Yorkshire Yorkshire Please provide details about the type of support you are seeking. Oncology History Diagnosis Select your diagnosis Breast Bowel Blood Gynae Prostate GI Cancer Kidney Lung Bone Sarcoma Head and Neck Skin Testicular Other If you have Ovarian Cancer please tick this box Diagnosis Date Surgery Yes No To come Type of Surgery Radiotherapy Yes No To come Chemotherapy Yes No To come Main reason for enquiry Already connected to a PINC & STEEL Physiotherapist and Clinic Name of Physiotherapist Name of Clinic If you do not have a Physiotherapist or Clinic, please write NONE above You must enable JavaScript to submit this form
