Support Contact Form

Contact Information

Country
Email*
Confirm Email*
Phone

Further Details

Please fill out the below details in order for us to better answer your question. 

Category*
  • Bereaved
  • Carer
  • Education Professional
  • Employer
  • Family Member
  • Friend
  • Health Professional/Org
  • Parent
  • Person Affected
Date of Birth (DD/MM/YYYY)
Demographics (please describe)

It is important to us to be able to engage with you and keep you up to date with the latest news about encephalitis and our work. This might include information about fundraising and research or other aspects of our work that help us meet our primary aim of improving the quality of all lives affected by this often-devastating condition. Please tell us how you prefer to hear from us and the different ways that we can keep in touch with you.

Consented to be contacted via (tick all that apply)*
  • Email
  • Post
  • Telephone
  • Newsletter - Email Only
  • Newsletter - Post only

By submitting this form you are also agreeing to the Encephalitis Society holding the information contained within on our database, this information will be kept in accordance with the Data Protection Act 1998. You have the right at any time to request your information be deleted from our database please contact the Society directly. 

Please put your enquiry below

Additional Comments

Share This Form

Powered by eTapestry.