University Hospitals Birmingham NHS Foundation Trust

Forms

Home

Membership registration form

Please provide your address.

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 select all that apply.
Have you ever been a patient at Birmingham Chest Clinic, Heartlands Hospital, Good Hope Hospital, Queen Elizabeth Hospital Birmingham or Solihull hospital? *
Do you care for somebody who is a patient at one of the above hospitals? *
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:

These details will be stored on our membership database for the duration of your membership and will be used to send you communications relating to your membership.

Please tell us your communication preferences*: *

* please note that even if you have chosen not to be contacted by email or not to be contacted by us regarding your membership at all, you will still receive a one-off automated email upon completing this form for the purpose of confirming your registration and providing important information about how to change your communication preferences at a later date.

Delivering the best in care
Back to top