British Society of Paediatric Gastroenterology Hepatology and Nutrition

Change of Details Form This update form is only for current members. If you wish to join the BSPGHAN as an associate member please download the proposal form. Your details can be updated by downloading the Membership Registration Form and posting or emailing this back to our secretary or alternatively you can complete the online form below which will be automatically sent to our secretary:
Membership Details
Title :
First Name:
Middle Name:
Surname:
Previous Surname:
Preferred Name:
GMC Number (if applicable):
Primary Institutional Affiliation:
Secondary Institutional Affiliation:
Deanery (if applicable):
Employer:	NHS University other* (see below)
if other* above:
Full Member Category (Please select only one)	Consultant Medical Trainee Staff Grade/Associate Specialist Non Clinical Scientist International Other*(see below)
if other* above:
Full Member Terms	Full Time Part Time
Associate Member Category	Dietitian Nurse Psychologist Pharmacist Speech and Language Therapist Other
if other* above:
Associate Member Terms	Full Time Part Time
Contact Details
Work Address (for correspondence):
Home Address:
Degrees/Diplomas (for correspondence):
Telephone (Work):
Telephone (Home):
Mobile number:
Fax Number:
E-mail Address:
I agree for the following information to be published, please tick:	Work Telephone Home Telephone Mobile Telephone Fax E-mail
Special Interests
Clinical Activity: Choose most appropriate description	Gastroenterology, Hepatology & Nutrition Gastroenterology Hepatology Nutrition
Main Areas of Interest: Please tick all that apply	Clinical Practice Patient Based Research Laboratory Based Research Epidemiology
Confidential Information
Date of Birth:
Sex:	Male Female
Anticipated year of Retirement:
Name of Standing Account Holder:

Your details will be sent to Mrs Lloyd who manages secretarial services for BSPGHAN

Change of Details Form

Membership Details

Contact Details

Special Interests

Confidential Information