Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Patient
Please Note: As per our constitution, public membership is only available to those who reside within England. If you live outside of England your membership application will be rejected. Alternatively, if you have been a patient at any of our sites in the last 6 years you can become a patient member.
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Capt
Wing Commander
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Lord
Rabbi
Guardian
Nurse
Sir
Father
Other
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Transgender
Please enter your postcode, click Get Address, then select the correct address from the resulting list. If you cannot find the correct address please manually fill all address fields (including postcode).
Address *
Town or City
County
Postcode *
Country
The trust is committed to saving money on printing, paper and postage and therefore only communicates regularly with members via email.
Home telephone
Mobile
Email *
Twitter
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
2. Additional Information
Do you consider yourself to have a disability?
No
Yes
Blind or partially sighted
Communication disability
Deaf or hearing impaired
Learning difficulty
Mental health condition
Mobility difficulty
Any other special need (please state)
How would you like to be involved?
Consider standing for election as governor
Recieve information
Attend meeting and events
Service preferences?
Accident and emergency
Alternative therapies
Asthma
Audiology
Breast screening
Cancer services
Cardiology
Charity work
Children’s services
Community based services
Dementia
Dentistry
Dermatology
Diabetes
Elderly and frailty medicine
Finance
Flu
Gastroenterology
Heart services
HIV services
Immunology
Infectious diseases
Intensive care
Kidney services
Liver services
Maternity
Medicine
Mental health
Multiple sclerosis
Neuroscience
Nutrition and dietetics
Occupational health and wellbeing
Ophthalmology
Organ donation
Out patients
Pain management
Palliative care
Parking
Parkinson’s
Pharmacy
Physiotherapy
Plastic surgery
Radiology
Research and development
Rheumatology
Sexual health
Stroke services
Trauma and orthopaedics
Tuberculosis
Urgent care centre
Urology
Vascular surgery
Volunteering
Waiting times
Women's services
How are you connected with the Trust?
A Patient
A Carer of someone who is a patient
Volunteer
Have previously worked for the trust
Bank (Staff)
Fixed Term Temp (Staff)
Honorary (Staff)
Locum (Staff)
Non-Executive Director / Chair (Staff)
Permanent (Staff)
How did you hear about the trust?
Pop up box online
Royal Free London NHS Foundation Trust website
Patient Mailing
Online Membership Form
Through a member of staff at Royal Free London NHS Foundation Trust
Face to Face Recruitment
Membership box
Advertisement
Event run by Royal Free London NHS Foundation Trust
Through a family member
Through a friend
Media
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
Twitter
Ethnic Origin
Do you consider yourself to have a disability?
How 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 Free London NHS Foundation Trust and 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.