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
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Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Transgender
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The trust is committed to saving money on printing, paper and postage and therefore only communicates regularly with members via email.
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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

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

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?

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