Avon & Wiltshire Roadshows – Booking Form

Wednesday 7th May – Engineers House, Clifton, BS8 3NB
Wednesday 14th May – The Hilton, Lydia Fields, SN5 8UZ
Wednesday 21st May – Trowbridge Rugby Club, BA14 6JB

Your name *

Pharmacy Name (write locum if not regularly in one pharmacy) *

Email Address (incase we need to contact you) *

Mobile Phone Number

Area of work * BANESBristolNorth SomersetSouth GloucestershireSwindonWiltshireAcross multiple areas

Number of people you are booking for *

Please select Date & Venue * Weds 7th May - Engineers House, Clifton, BS8 3NBWeds 14th May - The Hilton, Lydiard Fields SN5 8UZWeds 21st May - Trowbridge Rugby Club, BA14 6JB

If booking for more than yourself, please provide extra names (separated by a , )

Any special dietary requirements?

If you are human, leave this field blank.