Oxfordshire ME Group for Action SUBSCRIPTION FORM 2017

Please fill in this form and send it by post, or scan and email to:

David Polgreen, Hillview, Mill St., StantonSt John, OX33 1HQ

PLEASE REPLY AS SOON AS YOU CAN - it will really help us.

⃝I would like to start/renew my OMEGA membership for the next twelve months at a cost of

£10 or £5 (unwaged).

⃝ I would like to make a donation to the value of £______

How to pay: It would be a great help to us and the environment if you could pay by BACS using online or telephone banking: Sort code: 08-92-99, bank account 65412484 and quote your name as a reference (so we know who has paid). However if it is easier please just send a cheque to the address above.

Paid by: BACS ⃝ Cash. ⃝ Cheque (payable to OMEGA) ⃝

Total paid: £______

Name ……………………………………………………………………...…………………………. Date ………………………

Address………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………… Postcode………………….…

Tel No. ………………………………………………… Mobile number………………………………………….…………

Email address ………………………………………………………………….

Are you? a sufferer ⃝ carer ⃝ parent ⃝ someone with an interest in the illness (if so what) ⃝

………………………………………………………………………………………………………………………………………………..

Note: we never pass on your details to anyone else without your permission, and we don’t have adverts.

We can save energy by sending Newsletters and reminders of events by email. We plan to send the occasional email (approx. one per month) with meeting reminders and other information.

Where did you hear about OMEGA? friend/relative ⃝ leaflet/poster ⃝ health professional ⃝

online search ⃝other ⃝ (Please specify)…………………………………………………………………….…………...

Would you like to be on an email list for information and reminders? / Yes / ⃝ / No / ⃝
Would you like to receive the newsletter by email? / Yes / ⃝ / No / ⃝
Would you like to be on a telephone contact list available to all on the list?Yes / Yes / ⃝ / No / ⃝
Would you like to be in email contact with other members? / Yes / ⃝ / No / ⃝
Would you like to help OMEGA in any way? May we contact you? / Yes / ⃝ / No / ⃝

P.T.O.

Help with research:

OMEGA is supporting Karl Morten's biomedical researchin Oxford. This is a wonderful chance for members to become involved. Would you like more details of this research with a view of helping when further information is available? Yes ⃝ No ⃝

Have you been diagnosed with ME or CFS by a health professional? Yes ⃝ No ⃝

There are two NHS services in Oxfordshire:

One is the community service calledOxfordshire CFS/ME Service (their GP is Dr Fiona Duxbury) .

Have you been referred to this service?Yes ⃝ No ⃝

The other Oxfordshire service based in the Oxford hospitals is called OUH Chronic Fatigue Service (Dr Brian Angus)

Have you been referred to this service? Yes ⃝ No ⃝

If you have you been treated by either of these, did you find them helpful?

⃝ Veryhelpful ⃝ Somewhat helpful ⃝ Neither helpfulnor unhelpful

⃝ Not very helpful ⃝ Not at all helpful

What would you have liked them to do that they didn’t do?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

OMEGA is on Twitter: Follow @omega_oxon

Our website is: omegaoxon.org

Facebook page: - search ‘Oxfordshire ME Group for Action’

All have details of forthcoming events.

Enquiries: