EAI Membership Form

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EAI Membership Form

Email *

Confirm you are over 18 years *

Yes

Required

Geographic Location

Republic of Ireland

Northern Ireland

Other:

Clear selection

Gender (Optional)

Female

Male

Transgender

Non-Binary

Prefer not to say

Other:

Clear selection

Reason for Membership (Optional)

I have endometriosis

I have adenomyosis

I have both endometriosis/adenomyosis

I support someone with endometriosis/adenomyosis

I suspect I have endometriosis/adenomyosisis

Clear selection

Age or age of person you support with endometriosis (Optional)

12-17

18-25

26-35

36-49

50-57

58-65

66-73

74-81

82-89

90+

Clear selection

Where are you in your journey with Endometriosis?

Seeking Information

Awaiting diagnosis

Recently diagnosed

Seeking information on treatment and pain management

Seeking information on fertility

Perimenopausal

Menopausal

Dealing with the impact of Endometriosis on daily life

Dealing with the impact of Endometriosis on mental health

Other:

Do you agree to receive communication from EAI?
*

Yes

Required

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Forms

This form was created inside of Endometriosis Association of Ireland.