We are committed to engaging with all our communities, please complete as much of the form as possible to help us to target our engagement with you.
Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Ms
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 *
Preferred method of contact
Email
Post
Telephone
Text Message
What is your ethnic group?
Not stated
White - English, Welsh, Scottish, Northern Irish, British
White - Irish
White - Gypsy, Roma 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
What is your religion?
Not Stated
Buddhist
Christian
Hindu
Humanist
Jewish
Muslim
Sikh
No religion
Other
Do not wish to disclose
Sexual Orientation
Not Stated
Heterosexual or straight
Gay or Lesbian
Bi-sexual
Do not know / not sure
Prefer not to say
Is your gender identity the same as the gender you were assigned at birth?
Unspecified
Yes
No
Prefer not to say
2. Additional Information
If you would like information made available to you in another format, please tell us here:
Large Print
Audio tapes
Braille
Other (please state)
Do you consider yourself to have a disability or long term condition that limits your daily life?
No
Yes
A sensory disability
Hearing
Behaviour or emotional
A mental health problem
A physical disability
Long standing illness
A learning disability
Any other special need
How would you like to be involved? (please tick all that apply to you)
Complete surveys
Attend events
Receive information
Attend focus groups
Be involved in planning or monitoring the services commissioned by the ICB
Comment on service redevelopments
Volunteering
Are you interested in specific health topics? (please tick all that apply to you)
Children and young people's health and care
Community services
Diabetes
GP surgeries and primary care
Health improvement and reducing health inequalities
Hospital care
Learning disabilities
Long term conditions
Mental health and wellbeing
Older people's health and care
Muscoskeletal (muscles and bones)
Vascular care (hearts)
Prescribing
Respiratory
Integrated Care
SEND - (Special Educational Needs and Disabilities)
3. Review
Last Used Services
Title
First name
Last name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
What is your ethnic group?
What is your religion?
Sexual Orientation
Is your gender identity the same as the gender you were assigned at birth?
If you would like information made available to you in another format, please tell us here:
Preferred method of contact
Do you consider yourself to have a disability or long term condition that limits your daily life?
How would you like to be involved? (please tick all that apply to you)
Are you interested in specific health topics? (please tick all that apply to you)
4. Finish
*
I apply to join the Clinical Commissioning Group's patient involvement scheme and give consent to the processing of my information.
The data you supply will be used only to contact you about the CCG, membership or other related issues and will be stored in accordance with the current Data Protection Act. Please click
here
for full details.