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About you:

name *

address1 *

address2

postcode *

tel *

email *

date of birth

year of diagnosis 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988

About your condition:

I have been diagnosed with (please select):

Coeliac Disease

Dermatitis Herpetiformis

Coeliac Disease/Diabetes

Wheat Intolerance (other than Coeliac Disease)

Food Intolerance (other than Coeliac Disease)

other (please specify)

My diet must be:

gluten free milk free soya free

other diet (please specify)

Please tick here if your dietitian has told you to avoid gluten-free wheat starch

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From time to time we may wish to send you information about Juvela products and services that could be of interest. The information may be provided by letter, telephone, email or other reasonable means of communication. Please tick this box if you do not wish to be contacted