In this section

Living Lung Reg

Name *

Date of Birth *

Gender *

Disability *

Ethnicity *

Full address *

Telephone number *

Email address *

Tell us about your health *

Do you suffer from any cardiac conditions? *

no - I do not suffer from any cardiac conditions
yes - I do suffer from cardiac conditions

Have you been referred to the NHS Pulmonary Rehabilitation Team? *

no - I haven't been referred
yes - I have been referred

Would you like to receive a copy of our e-newsletter *

No thank you
Yes please

How did you hear about the programme? *

As a Local Authority we collect, hold and process information supplied by you in accordance with the Data Protection Act, to allow us to provide services effectively. You can find out more regarding this and our privacy notices here.

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