If you would prefer to print and mail your membership form please select from the following:
Patient / Carer / Partner Applicantions
All applicants must be over the age of 18 years and can be:
- the patient themselves
- a carer, partner or family member of an adult patient (we advise you seek permission from the patient first before disclosing their personal details)
- a carer, parent or family member of an infant/child/adolescent under the age of 18 years
ORIGINAL CONDITION: Please select only ONE from the drop down list. This is the primary cause of your pituitary problem ie. Acromegaly / Pituitary tumour: Non-functioning / Brain injury / Congenital.
CURRENT CONDITIONS: You can select up to 4 current conditions. These describe where you are at the moment.
- If your original condition has been resolved (in remission or successful treatment
Please select N/A to Current Condition 1
- If your original condition has not been resolved and you have no additional conditions
In Current Condition 1 please select the same condition as Original Condition
- If your original condition has been resolved, and you now find you have acquired other conditions since treatment (such as Panhypopituitarism or DI
Please select in Current Conditions 1, 2, 3 & 4 conditions you may have acquired or have currently – choosing 1 as most prominent (for example Panhyopituitarism)
- If your original condition has not been resolved, and you now find you have acquired other conditions since treatment (such as Panhypopituitarism or DI)
Please select in Current Condition 1 the same condition as Original Condition, then in 2, 3 & 4 select other conditions you may have acquired or have currently – choosing 2 as most prominent (for example Panhyopituitarism)
SURGERY: Please tick if you have had surgery. 4 selections will appear – allowing you to provide details
of multiple or different surgeries.
RADIOTHERAPY: Similar to surgery
Patient Contact Register
Some members have expressed the desire to be able to contact fellow members. The Phone and Email Patient Contact Register is designed to enable direct contact between patient or family / carer members with their permission. You might like to be part of this Register.