Please fill in your details below to become a member of RD&E NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Capt
Wing Commander
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Alderman
Brigadier
Commander
CDR RN
Dame
Group Captain
Lt Cdr
Lt Col
Prebendary
Rev Preb
Rev Dr
The Hon
Sqd Ldr
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
2. Additional Information
Disabilities
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
I'm happy to be contacted about meetings and surveys
Exclude from Postal Newsletter
Service preferences
Medicine
Cancer Services
Other support services (please list in ‘Notes’ section)
Antenatal/Maternity
Cardiology
Infection Control
Dermatology
Ear, Nose & Throat
Emergency Department
Gynaecology
Opthalmology
Orthodontics
Orthopaedic
Paediatrics
Surgery
Trauma
How are you connected with the Trust?
I am a member of a community organisation
I am a relative of a member of staff
I am a relative of a patient
I am a carer of a patient
Other (Please Specify)
I've been a patient at the RD&E
Stakeholder
How did you hear about the trust?
Direct Mail
Newspaper
From another member
At the Hospital
RDEFT Website
Governor Recruitment Session
Recruit a Friend
RDEFT Membership Stand
3. Review
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Preferred method of contact
Disabilities
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
*
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for full details.
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