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User Name
Email Address
Details
First Name
Last Name
Date Of Birth
dd/mm/yyyy
Centre
Royal Free
Leeds Teaching Hospital
Salford Royal
King's College Hospital NHS Foundation Trust
Clinical Immunology (Newcastle)
Nottingham
North Bristol NHS Trust
Southampton General Hospital
The Royal London Hospital
Manchester University NHS Foundation Trust
Royal Manchester Children's Hospital
Royal Preston Hospital
University Hospitals Bristol and Weston NHS Trust
Frimley Park Hospital
The walton Centre NHS Foundation Trust
St George's University Hospital Foundation Trust
Maidstone and Tunbridge Wells NHS Trust
University College London Hospitals
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Disclaimer
1) I agree to the
Terms and Conditions
2) I understand the purpose and nature of the IVIG Home Therapy system and give consent for my Treatment Centre to hold my treatment data and for it to be analysed anonymously for research audit purposes.
I agree to both statements above
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