Irritable Bowel Syndrome Self Help and Support Group

IBS Self Help and Support Group Electronic Membership Application Form:

Please complete fully and SUBMIT at the bottom of the page. All information will be strictly kept confidential.

Choose one of the following: New Address Change

Please identify and describe yourself:

First Name

Last Name

Middle Initial

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Please provide the following contact information:

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Home Phone

Work Phone

FAX

E-mail

IBS-Username on the IBS Self Help and Support Group Forums

Where Did You Find Out About the IBS Self Help Group?

Would you like to attend an IBS Self Help Group meeting in your area?

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Tell us more about yourself (check all that apply):

I have IBS
A family member/friend has IBS
I am a member of the medical profession
I wish to become more educated about IBS
Other

Comments:

I do not wish any of my contact information to be shared with support groups in my area.

Last updated January 17, 2006