Member type	Public Patient
Title	Unspecified Mr Mrs Miss Ms Dr Professor Sir Lord Dame Father Right Hon
First name *
Last name *
Middle name
Date of birth *	DD MM YYYY
Gender	Unspecified Male Female
	Please enter your postcode, and click Get Address
Address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
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

Special Postal Requirements	Large Print Braille/Audiotranslations Other Easy Read
Disabilities	No Yes A sensory disability A physical disability A learning disability A mental health problem Any other special need (please list in the 'Notes' section) Disabled Longstanding illness
How would you like to be involved?	Consider standing for election as governor Completed questionnaire Provide Feedback Participate in the election of Council of Governors Becoming a Volunteer Receiving Regular Information Attending meetings or events Interest in survey Receive an annual summary report Tour of Cancer Centre at Guy's Exclude from postal mailing
Service preferences?	Accident and Emergency Back Problems Cancer Children's Health Children's services Dental Dermatology Diabetes Ear, Nose and Throat Elderly Care Epilepsy Eye Problems General Haematology Heart Disease Hospital Cleanliness/Environment Hospital Food Immune system conditions Intestinal Conditions Kidney and Liver Problems Medicine Men's Health National Spinal Injuries Centre Neurology Other Outpatient services Pain Sexual Health Surgery Therapies Women's health
How are you connected with the Trust?	A current patient A past patient Support Worker Volunteer for Trust Work for Trust
How did you hear about the Trust?	Online Application Public meetings Public consultation mailing Other

Member type
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country	UK
Home telephone
Mobile
Email
Ethnicity
Special Postal Requirements
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?
How are you connected with the Trust?
How did you hear about the Trust?

*  I apply to be a member of Guy's and St Thomas' NHS Foundation Trust and be bound by the rules of the organisation. I give consent to the processing of my information.

The data you supply will be used only to contact you about the Trust, membership or other related issues and will be stored in accordance with the current Data Protection Act. Please click here for full details.

Please tick here if you consent to your details being added to the Public Register.