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• Title ^*
  - please select -MrMissMsMrsDrProfessorSir
• Forename ^*
• Surname ^*
• Address Line 1 ^*

  Not visible to public
• Address Line 2 ^*

  Not visible to public
• Town ^*
• County ^*

  Not visible to public
• Post Code ^*

  Not visible to public
• Send communications by ^*

  E-mail (preferred), S-mail, Both

  E-mail only E and S mail S-mail only
• Home Phone ^*

  Not visible to public
• Mobile Phone

  Not visible to public
• Send me Text message reminders 1 month before meetings
  Yes No
• Send me text reminders 1 week before events
  Yes No
• Send me Text message reminder 1 day before meetings I am attending
  Yes No
• Position ^*

  The title of you appointment or past appontment if retired
• Place ^*

  The hospital or practice name
• Employment Status ^*
  - please select -SubstantiveLocumTrainingRetired
• If you are a doctor in training approximate leaving date

  You will be e-mailed at this time to confirm
• 2nd e-mail address

  Private - non work address preferred
• This e-mail address preferred
  Yes No
• Membership request
  - please select -I am a paid memberI am an Honorary memberI wish to become a full paid memberI wish to be an associate memberI do not wish to be a member but would like to be kept informed
• A Picture of you
• Membership of the Medical Society Golf Club ^*

  choose "Member" if you would like to be a golfing member otherwise leave blank

  - please select -MemberNon member
• Golfing handicap

  If applicable