Please select your member type below using the following criteria
Public- if you live in England or Wales Patient- if you have been a patient at Guy’s, St Thomas’, Evelina, Royal Brompton or Harefield hospitals in the last 5 years Carer - if you are a carer of a patient of one of the above hospitals please click on ‘Patient’ and then select ‘Carer.’
Member type *	Public Patient
Title *	Unspecified Mr Mrs Miss Ms Dr Professor Sir Lord Dame Father Right Hon
First name *
Surname *
Middle name
Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Non-binary Prefer not to say
	Please enter your postcode, and click Get Address
Address *
Town or City
County
Postcode *
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Home telephone
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Email *
Preferred method of contact	Email Post Telephone SMS
Ethnicity *	Not stated White - English, Welsh, Scottish, Northern Irish, British White - Irish White - Gypsy or Irish Traveller White - Other Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Other Mixed Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Other Asian Black or Black British - African Black or Black British - Caribbean Black or Black British - Other Black Other Ethnic Group - Arab Other Ethnic Group - Any Other Ethnic Group

Hospital Affiliation *	Royal Brompton Harefield Guy's St Thomas' Evelina
Disabilities	No Yes A sensory disability A physical disability A learning disability Mobility difficulty Communication difficulty Blindness or partially sighted Deaf or hearing impaired A mental health condition Any other special need (please list in the 'Notes' section) Disabled (Prefer not to say)
How would you like to be involved?	Stand for election as Governor Volunteer at one of our hospitals Get involved in activities to develop and/or improve services Learn more about patient and public engagement opportunities Support the work done by the charities
We involve patients and carers in helping us to develop and improve our services. Please select all the service and areas that you have experience of as a patient or carer, as well as any other areas that you have a strong interest in.
Experience and interests	All of the above Cardiology services Care environment Chaplaincy Volunteer Children's services Critical Care Cystic Fibrosis Adults Care End of life care Fair and equitable access to services Inpatient services Massage Therapy Men's Health Oncology services Other, please specify Outpatient services Research Respiratory services Surgery services Transplant services Urgent and emergency services Use of technology in delivering health services Volunteer Meet and Greet Women's health
How did you hear about the Trust?	Membership leaflet Member of Staff Via the Trust website Other

Member type *
Last Used Services
Title *
First name
Surname
Middle name
Date of birth
Gender
Address
County
Postcode
Country	UK
Home telephone
Mobile
Email
Ethnicity *
Hospital Affiliation
Preferred method of contact
Disabilities
How would you like to be involved?
Experience and interests
How did you hear about the Trust?

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