Thank you for your interest in obtaining further copies of the Back Book. You can order a supply for your own use or on behalf of the Practice. Please indicate below the amount of Back Books which you require. Also, there's no limit on the amount of orders that you are allowed to place and no cost will be incurred for additional orders. Please note that copies of 'The Back Book' are being provided to you free of charge. However, you will receive documentation with your delivery informing you of the cost of these resources but we request that you ignore this as it is for information only and does not require any further action on your behalf. These resources have been prepaid by Public Health Wales. To help us to deliver the books to the correct address we would be grateful if you could register your details below. At the end of the registration process there is a link to the ‘Healthy Working Wales’ website.

	Title	Dr Miss Mr Mrs Ms Prof Sir
	Firstname*
	Surname*
	Email*
	Telephone
	Delivery address - this address will be used for the parcel label
	Address line 1*
	Address line 2
	Address line 3
	Address line 4
	Postcode
	Practice name
	LHB*	Anglesey Local Health Board Blaenau Gwent Local Health Board Bridgend Local Health Board Caerphilly Local Health Board Cardiff Local Health Board Carmarthenshire Local Health Board Ceredigion Local Health Board Conwy Local Health Board Denbighshire Local Health Board Flintshire Local Health Board Gwynedd Local Health Board Merthyr Tydfil Local Health Board Monmouthshire Local Health Board Neath Port Talbot Local Health Board Newport Local Health Board Pembrokeshire Local Health Board Powys Local Health Board Rhondda Cynon Taff Local Health Board Swansea Local Health Board Torfaen Local Health Board Vale of Glamorgan Local Health Board Wrexham Local Health Board

	Designation*	Practice Manager GP Occupational Health Physiotherapy Pain Management Services Orthopaedic Services Rheumatology Condition Management Programme Exercise on Referral Other
	Number of Back Books required*	10 20 30 40 50 60 70 80 90 100 150 200 250 300 350 400 450 500

	* Mandatory fields