Please fill in your details below to become a member of Lancashire Teaching Hospitals NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Staff
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Capt
Wing Commander
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Councillor Mrs
Reverend Canon
Reverend Dr
Sir
His Honour Judge
Lord
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
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
Special Postal Requirements
Large type (please specify preferred font size)
Braille
Audio
Opt out of receiving newsletter
Disabilities
No
Yes
Prefer not to say
Any Special Requirements?
How would you like to be involved?
I am interested in becoming a governor
Low involvement (level 1)
Medium involvement (level 2)
High involvement (level 3)
Areas of interest
Long term conditions
Orthopaedics and rheumatology
Children and young people
Emergency
Specialist services (kidney, brain, nervous system, plastic surgery, wheelchair & prosthetics)
Surgery (including conditions of the urinary tract, digestive and circulatory systems)
Cancer
General medicine (including heart and digestive system illnesses)
Older people
Men’s health
Women's health
Hospital environment
Out-patient clinics
Other (please specify)
Recruitment
Research Studies
How are you connected with the Trust?
Current patient or have been a patient within the last 3 years.
A carer of someone who is a patient
Volunteer
Have worked for Trust
Other (please specify)
How did you hear about the Trust?
Patient mailing
Face-to-face recruitment
Radio advertisement
Through an employee of the Trust
Through another FT member
Outpatient letter
Other (please specify)
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
Special Postal Requirements
Preferred method of contact
Disabilities
How would you like to be involved?
Areas of interest
How are you connected with the Trust?
How did you hear about the Trust?
4. Finish
*
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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
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for full details.
Please tick here if you consent to your details being added to the Public Register.