How involved would you like to be?
High Involvement Medium Involvement Low Involvement

Where did you hear about membership?
Hospital website
Social media
Leaflet
Information stand
Hospital newspaper
Friend or family member
Hospital staff or volunteer
Other

If you have a particular interest in one or more areas of healthcare, we'd very much like to know. Please tell us here:
Accident & Emergency Services
Arthritis & Joints
Breast & breast pain services
Cancer treatment
Diabetes
ENT
Elderly Care
End of life care
Eye Care
General health services
Heart
Kidneys
Liver
Lungs
Mental health services
Organ donation
Physiotherapy
Stomach and digestive system
Other
 

Have you ever been a patient in Heartlands, Good Hope, Solihull hospitals or in the Birmingham Chest Clinic?
Yes No

Do you care for somebody who is a patient in Heartlands, Good Hope, Solihull hospitals or in the Birmingham Chest Clinic?
Yes No

Please let us know your employment status

If other, please state:

Are you male or female?
Male Female

What is your ethnic origin?
Asian (Bangladeshi)
Asian/(Indian)
Asian/(Pakistani)
British Asian
Asian or British Asian (other)
Black African
Black Caribbean
Black British
Black (other)
Chinese
White British
White Irish
White (other)
Other
 

Are you registered disabled?
Yes No

If you need us to send you information in any of the following formats, please tick the relevant boxes:
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