ME North East
Printable Membership Form

Membership is Free
Easy Access to our Services
Newsletters provided quarterly
Everyone welcome to join us


To become a member simply complete this form and return it to ME North East, Bullion Hall, South Approach, Chester le Street, Co Durham DH2 2DW. Family members are also welcome, you will automatically be included on our mailing list and will receive our quarterly newsletter keeping you up to date with our organisation and what’s happening for ME in the North East region.


Name ………………………………………………………………

Address …………………………………………………………………….

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Post Code ………………………….. Tel No ……………………………..

E-mail………………………………………………………………………..

Date of Birth …………………………Patient/Carer………………………

Have you had a positive diagnosis Yes/No
If yes please give details of who diagnosed you?
Own GP/Hospital/Other (state)
……………………………………………

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Your GP’s Name/Practice………………………………………………….


Signature……………………………………………………………………..

Date……………………………………………..