Registration Details for Wellbeing Workshops – Type 2 Diabetes

Registration Details for Wellbeing Workshops - Type 2 Diabetes

"*" indicates required fields

Person Attending Details*

Title First Last

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Email*

Your GP Name & Address*

Please confirm you have Type 2 Diabetes?*

Yes

Course Time Preferred*

Comments/Additional Information you wish to add

Please confirm you are happy to be contacted by phone and/or email by Diabetes Ireland*

Yes

How did hear about this Course?*