Please fill in your details below to become a member of Royal Brompton & Harefield NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
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
Other
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
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)
Would you like to be involved?
Stand for election as a Governor
Comment on general hospital patient information
Take part on surveys & consultations on Trust’s plans
Sit on a patient panel
Join a website user group
Attend or speak at trust committees
Input into service design/redesign
Volunteer at the Trust
Support work done by the charities
Service preferences
Congenital Heart Disease
Coronary Artery Disease
Heart Valve Disease
Cardiac arrhythmias
Critical Care
Other cardiac disease
Cystic fibrosis
Asthma
Chronic Obstructive Pulmonary Disease
Interstitial Lung Disease
Other Respiratory Disease
Transplantation
How are you connected with the Trust?
Current or former patient of Royal Brompton Hospital (within the last 3 years)
Current or former patient of Harefield Hospital (within the last 3 years)
Interested member of the public
Carer of a current/former patient of Royal Brompton Hospital (within the last 3 years)
Former RBHT staff member
How did you hear about the Trust?
Patient Mailing
Trust website
Through an employee of the Trust
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
Preferred method of contact
Do you consider yourself to be disabled?
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 Royal Brompton & Harefield 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.