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Date: 23 October 2014

Time: 07:40

Become a member today: membership registration form

Please note that the contents of this form will not be encrypted upon submission. If you would prefer not to use this form to submit your information, please call us on 0121 371 4323.

Please choose one of the four ways to be a member: *
 
 
 
 
Where did you hear about membership? *
 
 
 
 
 
 
 
 
If you have a particular interest in one or more areas of healthcare, we'd very much like to know. Please tell us here:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have you ever been a patient at Queen Elizabeth Hospital Birmingham, the old QE or Selly Oak Hospital?
  
Do you care for somebody who is a patient at Queen Elizabeth Hospital Birmingham, the old QE or Selly Oak Hospital?
  
Are you male or female? *
  
Ethnic origin: *
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are you registered disabled?
  
If you need us to send you information in any of the following formats, please tick the relevant boxes: