New Family registration form

PACT must comply with all current legislation. Your information will be kept safe, secure, and treated with care and respect.

Information will only be ever used, shared and/or stored strictly within the requirements of the Data Protection Act 2018.

NB: If the patient is 16 or over and have the capacity to consent to their information being stored, they must also sign this form.

Patients name

Signature (if over the age of 16)

Address

Phone

Email

Birthday

Date of Diagnosis

Diagnosis (must comply with PACT support and eligibility criteria)

We offer our support to every family who is referred to the Oncology unit at Sheffield Children’s Hospital and whose child has Cancer, Leukaemia or Aplastic anaemia irrespective of where they live.