Please fill in your details below to become a member of Guy's and St Thomas' NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
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
2. Additional Information
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
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
3. Review
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?
4. Finish
*
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.