Latex Allergy Support Group

Membership form

• Title: Ms Miss Mrs Mr Dr
• First Name:
• Last Name:
• Email address:
• Password:

Please note we NEVER share your personal data.

• Postal Address Line 1
• Postal Address Line 2
• Town / City
• County
• Post Code
• Tel (Home)
• Tel (Daytime if different from above)
• Date of Birth (optional) (dd/mm/yyyy)

Reason for wanting to join the Latex Allergy Support Group

I am allergic to natural rubber latex
A friend or family member is allergic to natural rubber latex
I have a professional interest in latex allergy

The annual membership fee is a minimum of £10. Any other additional contribution would be welcome.

Thank you for your support.