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HHT Ireland Member Form
I authorise HHT Ireland to process my personal data for the purpose of spreading awareness in Ireland about HHT disease & treatment and creating a national community of patients & families.
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Surname
*
Your answer
Address Line1
*
Your answer
Address Line2
Your answer
Town
*
Your answer
County
*
Your answer
Postcode
Your answer
Phone number
*
Your answer
I have HHT in the following:
*
Nose
Mouth
Gastro Intestinal
Brain
Lungs
Liver
Skin
None of the above
I don't have HHT
Required
I myself don't have HHT, but am a
*
Partner
Parent
Sibling
Child
None of the above
Not Applicable
Required
Are there other family members with HHT who might be interested in hearing from us?
*
Yes
No
If YES to the previous question, are you happy to direct them to our website www.hhtireland.org to become a member?
*
Yes
No
General Comments
Your answer
On submission, you will now be added to our HHT Ireland family!
Many thanks from the Team at HHT Ireland
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