Register with IMNDA

Register with IMNDA

Please note this form is for somebody with a confirmed diagnosis of Motor Neurone Disease. If you are registering on another person’s behalf, please ensure you have discussed this with them, and they have given consent for you to share their details with us. The person must be a resident of the Republic of Ireland. If you experience any difficulties completing this form, please call the office on 01 670 5942. Thank you.
Salesforce fields hidden
Your Details

Or details of individual with confirmed diagnosis of Motor Neurone Disease, if you are registering on another person’s behalf.
Name*

First NameLast Name
Address*

Address Line 1

Address Line 2
Town/CityCountyEircodeCountry
Birthdate*

DayMonthYear
Date
Telephone*
Please enter a valid phone number.
Email address
example@example.com
Occupation
What are your current living arrangements?

With FamilyAloneResidentialOther
Please Give details

0/800
Contact Preferences
One of our nurses will contact you following registration. Who is it best to call?*

The person with MNDNominated Contact
Does Client wish to receive contact?

YesNo
Contact through NOK

YesNo
Ongoing Contact

We will only contact you when relevant. Please let us know how you wish to receive contact from us.
Phone*

YesNo
Email*

YesNo
Postal*

YesNo
Home Visit by an IMNDA Nurse*

YesNo
Text Messages*

YesNo
IMNDA Contact requested

PhoneMailHome VisitEmailText Message
Would you like to receive the IMNDA Information Booklet*

Yes - Send it to meYes - Send it to my Nominated ContactNo
How would you like to receive IMNDA Information Booklet*
Nominated Contact Details
Name*

First NameLast Name
Address*

Address Line 1

Address Line 2
Town/CityCountyEircodeCountry
Telephone
Please enter a valid phone number.
Email Address
example@example.com
Relationship*
Does your nominated contact person wish to receive communications from the IMNDA?
Phone*

YesNo
Email*

YesNo
Postal*

YesNo
Text Messages*

YesNo
NOK Contact Requested

PhoneMailEmailText Message
Symptoms
When did Symptoms occur
Symptoms Notes
Healthcare Team
Date of Diagnosis*

DayMonthYear
Date
Diagnosis made by (Consultant)*
Diagnosis made in (Hospital)*
GP Name*
Do you have a medical card?*
Are you using the medication Rilutek/Rilizole?*
Are you agreeable to us discussing your case with the relevant healthcare professional should the need arise?

YesNo
Additional info from web form
Should be Empty:

Register with IMNDA

Salesforce fields hidden

Your Details

Contact Preferences

Ongoing Contact

Nominated Contact Details

Does your nominated contact person wish to receive communications from the IMNDA?

Symptoms

Healthcare Team