Irish Motor Neurone Disease Association : 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.

Your Details

What are your current living arrangements?

With family
Alone
Residential
Other

Please give details:

One of our nurses will contact you following registration.
Who is it best to call? *

The person with MND
Nominated Contact

Ongoing Contact

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

Home Visit by an IMNDA Nurse *

Yes
No

Text Message *

Yes
No

Yes - Send it to me
Yes - Send it to my Nominated Contact
No

When did symptoms start to occur?

Diagnosis made by (Consultant Name): *

Diagnosis made in which hospital? *

Are you agreeable to us discussing your case with the relevant healthcare professional should the need arise? *

Yes
No

Do you have a medical card?

Yes
No

Are you using the medication Rilutek/Rilizole?

Yes
No

Please tell us anything else you feel is relevant

Registered Charity No. 20021009

Register with IMNDA

Your Details

Contact Preferences

Ongoing Contact

Nominated Contact Details

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

Symptoms

Healthcare Team