Member type	Public Staff Patient
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Wing Commander Capt Col Major Commodore Cllr Sister Master Lady Mayor Lieutenant colonel Reverend Dr Sir Baroness
First name *
Last name *
Middle name
Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Transgender
	Please enter your postcode, and house name or number
	Postcode House name/number
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

Do you consider yourself to be disabled?	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)
How would you like to be involved?	Consider standing for election as governor Take part in consultations & surveys of the Trust's plans. Volunteer at the Trust Commenting on general hospital patient information Learning more about being a member of a `Patient Panel’ to provide feedback on my experiences Attend or speak at trust commitees Being available to sit on a website user group
Service preferences?	Heart Lung Children Transplant Cancer Organ Donation Research Quality Improvement e.g. audits Rehabilitation & Therapies Medicines Infection Control Disability Diagnostics e.g. Tests & Investigations X-rays, CT, MRI
How are you connected with the Trust?	Current or former patient (within the last 3 years) Carer of a current/former patient (within the last 3 years) Interested member of the public Member of the RBH & HH Alumni
How did you hear about the Trust?	Patient Mailing Radio advertisement Through an employee of the Trust

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

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