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Form M002

MISOPHONIA UK

Practitioner website listing request

PLEASE COMPLETE IN BLOCK CAPITALS

Name……………………………………………………………………………………

Professional address………………………………………………………………….

…………………………………………………………………………………………..

Tel…………………………………… Fax……………………………………............

Email…………………………………………………………………………………….

Qualifications…………………………………………………………………………..

Professional body……………………………………………………………………..

Professional registration number (GMC if UK-registered doctor)…………….......

Professional knowledge/experience of misophonia………………………………..

I consent to this record being retained in electronic format by Misophonia UK.

Signed…………………………………………………………. Dated………………..

Please note that if this form is not filled out in full, it may not be possible to process your listing request.

For official use only: Date rec’d: Checked: Actioned: