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
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Home address *
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Postcode *
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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

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)

Member type
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Title
First name
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Address
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Country	UK
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Please describe your ethnic origin:
Please select the option which best describes your sexuality:
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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?

*  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.

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