Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Staff
Patient
Title
Unspecified
Canon
Capt
Cllr
Col
Commodore
Dame
Dr
Lady
Lord
Lt Col
Major
Master
Mayor
Miss
Mr
Mrs
Ms
Professor
Rabbi
Rev Dr
Reverend
Sir
Sister
Wing Commander
First name *
Last name *
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Transgender
Please enter your postcode and click Get Address
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Twitter
Preferred method of contact
Email
Post
Telephone
SMS
Please describe your ethnic origin:
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
Please select the option which best describes your sexuality:
Not Stated
Heterosexual
Bi-Sexual
Bi-Curious
Homosexual
Pansexual
A-Sexual
2. Additional Information
Special postal requirements
Large Print
Audio tapes
Braille
Other (please state)
Languages
English
Other
Require Intepreter for focus groups
Do you consider yourself to have a disability?
No
Yes
Prefer not to say
A sensory disability
A physical disability
A learning disability
A mental health problem
Any other special need (please state)
GP
Unspecified
AEGIS MEDICAL CENTRE
Ashingdon Medical Centre
Audley Mills Surgery
Aveley Medical Centre
Baddow Village Surgery
Balfour Medical Centre
BALLARDS WALK SURGERY*
Beacon Health Group (Danbury, Moulsham Lodge & Mountbatten Surgery)
Beauchamp House Surgery
BEECHWOOD SURGERY BRENTWOOD
Benfleet Surgery
BILLERICAY MEDICAL PRACTICE
Blackwater Medical Centre
Blandford Medical Centre
Blyths Meadow Surgery
Brickfields Surgery
Brimpton House
Carnarvon MC
Central Surgery North Rd PCC
Central Surgery Southchurch Blvd
Chafford Hundred Medical Centre
CHAPEL STREET SURGERY
Chelmer Village Surgery
Church Lane Surgery
Church View Surgery
CLAYHILL MEDICAL CENTRE
Coggeshall Surgery
Collingwood Road Surgery
Commonwealth Health Centre
DEAL TREE HEALTH CENTRE
Dengie Medical Partnership
Derry Court Medical Centre
Dickens Place Surgery
Douglas Grove Surgery
Downhall Park Surgery
DR ARAYOMI - DIPPLE MEDICAL CENTRE
Dr Bekas
Dr Chaudhury
Dr Connor & Ptns
Dr Dhillon
Dr Ghauri
Dr Khan & Ptns
Dr Krishnan
Dr Kumar & Ptns
Dr Malik
DR NASAH - DIPPLE MEDICAL CENTRE
Dr PA Patel
Dr Palacin
Dr Puzey, Kothari & Nanda
Dr Richards
Dr Sathanandan
DR SIMS & PARTNERS - DIPPLE MEDICAL CENTRE *
Dr Sooriakumaran
East Thurrock Road Medical Centre
East Tilbury Medical Centre
Eastwood Group Practice
Elizabeth Courtauld Surgery
Essex Way Surgery
FELMORES MEDICAL CENTRE
Fern House Surgery
Freshwell Health Centre
FRYERNS MEDICAL CENTRE
Greenwood Surgery
Hassengate Medical Centre
Hedingham Medical Centre
High Road Family Doctors
Highlands Surgery
HIGHWOOD SURGERY
Humber Road Surgery
Kelvedon & Feering Health Centre
Kingsway Surgery
KINGSWOOD MEDICAL CENTRE
KNIGHTS SURGERY
LAINDON MEDICAL GROUP
LANGDON HILLS MEDICAL CENTRE*
Little Waltham & Gt Notley Surgeries
LONDON ROAD SURGERY
Longfield Medical Centre
MATCHING GREEN SURGERY
Medic House
Melbourne House Surgery
MOUNT AVENUE SURGERY
Mount Chambers Medical Practice
MUREE MEDICAL CENTRE
Neera Medical Centre
NEW FOLLY SURGERY
NOAKBRIDGE MEDICAL CENTRE
North Avenue Surgery
North Chelmsford NHS Healthcare Centre
North Shoebury Surgery
Oaklands Surgery
Oddfellows Hall Health Centre
Pear Tree Surgery
Primecare Medical Centre
Pump House Surgery
Purfleet Care Centre
QUEENS PARK SURGERY
Queensway MC
Rivermead Gate Medical Centre
ROBERT FREW MEDICAL PARTNERS *
ROCKLEIGH COURT SURGERY
ROSE VILLA SURGERY
Sai Medical Centre
Scott Park Surgery
Silver End Surgery
SOUTH GREEN SURGERY
Southend MC
Southend Road Surgery
St George's Medical Practice
St Luke's HC
Stifford Clays Medical Practice
Stock Surgery
Sutherland Lodge Surgery
SWANWOOD PARTNERSHIP
Tennyson House Surgery
THE ARYAN PRACTICE
The Burnham Surgery
The Dell Medical Centre
The Grays Surgery
The Greensward Surgery
The Health Centre
The Hollies Surgery
The Island Surgery
THE KNARES SURGERY
The Laurels Surgery & Sidney House
The Leigh Surgery
The Milton Road Surgery
THE NEW SURGERY, BILLERICAY
THE NEW SURGERY, SHENFIELD
The Pall Mall Surgery
The Practice Leecon Way
The Practice Northumberland Ave
The Rigg Milner Medical Centre
The Sancta Maria Centre
The Shaftesbury Surgery
The Sorrells Surgery
The Surgery, Horndon-on-the-Hill
The Surgery, Orsett
The William Fisher Medical Centre
The Writtle Surgery
Third Avenue Health Centre
Thorpe Bay Surgery
Thurrock Health Centre
Tilbury Health Centre
TILE HOUSE SURGERY
Tollesbury Surgery
Trinity Medical Practice
Valkyrie Surgery
Wakering Medical Centre
Warrior Square Surgery
West Rd
WESTERN RD SURGERY
Whitley House Surgery
William Harvey Surgery
Witham Health Centre
Wyncroft Surgery
Employment status
Not Stated
Caring for a child or an adult
In full time education
Looking after home
On a government training scheme
Permanently sick or disabled
Unemployed - Registered Job Seeker
Unemployed - Unregistered but seeking work
Working full time (30+ hours per week)
Working part-time (less than 30 hours per week)
Wholly retired from work
Other please specify
Home type
Not Stated
Owned Right
Owned with a mortgage
Private Rented
Rented from the local authority
Rented from a housing association
Other
How would you like to be involved?
Online Surveys
Online surveys and focus groups/workshops
Service preferences?
Community Safety and Crime
Hospital Care
GP's
Housing and improving neighbourhoods
Long Term Conditions
Local enviroment and infrastructure
Leisure and Culture
Mental Health
Prevention, self care and wellbeing
Social services and care
Services for children and young people
Technology
Volunteering
Other support services (please state)
How are you connected with the Partnership?
Dependants under 16?
Carer?
Are you a member of local/community organisations
Are you a governor at an organisation?
How did you hear about the Partnership?
Recruitment 2020
Online Application
Public meetings
Public consultation mailing
Other (please state)
3. Review
Member type
Last Used Services
Title
First name
Last name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Twitter
Please describe your ethnic origin:
Please select the option which best describes your sexuality:
Languages
GP
Home type
Employment status
Special postal requirements
Preferred method of contact
Do you consider yourself to have a disability?
How would you like to be involved?
Service preferences?
How are you connected with the Partnership?
How did you hear about the Partnership?
4. Finish
*
The details that you provide on the membership application form will be kept completely confidential, and will be stored by Civica Engagement Solutions, the independent organisation that manages the panel on behalf of Mid and South Essex Health and Care Partnership. Civica Engagement Solutions is a Market Research Society Company Partner and fully adheres to the Data Protection Act 2018. To agree to become a Virtual Views member of Mid and South Essex Health and Care Partnership please tick the box. The information you provide us will only be used for matters pertaining to the Virtual Views Panel. Our privacy notices can be viewed
here
.
The data you supply will be used only to contact you about the Partnership, 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.