Patient Registration Form

Is there anything you’d like to tell us about or ask us right now? For example, you may be worried about treatment or your family’s finances or you may want more information about the condition.

If you would like one of the team to get in touch then please tell us a bit more about the support or information you are looking for. A member of our support team will respond to you within 1-2 working days.

If you’d like a free copy of our new planner, to help you keep track of tests result, appointments and more, please let us know in this box and provide your address below.

Your double birthday date. Many families celebrate the date of their stem cell/bone marrow transplant as a ’second birthday’. If that’s you - fill in this field and we’ll send you a Double Birthday Card on this date.

What stage would you consider yourself to be at regarding your condition?

Recently diagnosed and seeking more information to help me understandOn Watch and Wait (pre-treatment monitoring)Receiving treatmentAwaiting or in recovery from a bone marrow transplantNavigating life with the conditionHave been living with the condition a long time and looking for ways to move forward with lifeDealing with longer term difficult outcomes

Do you have any disability or access needs that would be helpful for us to consider if we get in touch with you? For example if you struggle with mobility or need information in a larger font type for reading, you can tell us about that here.

If you are in our Facebook group, or would like us to send you an invitation to join, you can add a link to your Facebook profile here to let us know who you are.

Would you be interested in being invited to volunteer in the following ways? (You can always change your mind later.)

Join online group discussions to share my opinions and improve healthcare services and treatmentHelping out on the day at an event near meHelping to organise an event near meTrain to be a moderator on our Facebook groupShare your story on our website (or in the magazine) for other people to read aboutTake part in a running event as a fundraiserTake part in another kind of sporting event as a fundraiserTake part in a cold water dip at Christmas timeRun a coffee morning in my local area

How did you hear about The Aplastic Anaemia Trust?

Recommended by a healthcare professionalRecommended by a friend or family memberSocial mediaOnline searchA poster, leaflet or booklet in the hospitalAt a conference or event

We ask you for this information so that we can make sure that when The Aplastic Anaemia Trust represent or consult with patients and families, we are representing the breadth and diversity of people who live in the UK. This is important because we believe people’s experiences of living with aplastic anaemia, receiving treatment, and navigating the healthcare system can be different and we want to do our best to represent everyone.

You can just leave this section blank if you’d prefer not to share this information.

Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the box that feels right for you.

Patient Registration Form

We are here for you.

Tell us more about yourself

The Aplastic Anaemia Trust and you

Your ethnicity and gender