Become a member

Title

First name

Last name

Please provide your address.

Address line 1

Address line 2

Town/city

Region

Country

Postcode

Telephone number

Email address

Date of birth (DD/MM/YYYY)

Where did you hear about membership?

Hospital website
Social media
Leaflet
Information stand
Hospital newspaper
Friend of 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 select all that apply.

Other healthcare interests (please state)

Have you ever been a patient at Birmingham Chest Clinic, Heartlands Hospital, Good Hope Hospital, Queen Elizabeth Hospital Birmingham or Solihull hospital?

Yes
No

Do you care for somebody who is a patient at one of the above hospitals?

Yes
No

Please tell us your employment status:

If other, please state:

Are you male or female?

Male
Female

Ethnic origin

If other, please state:

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:

Braille
Large font
CD-ROM

Please tell us your communication preferences*

I am happy to be contacted by post
I am happy to be contacted by telephone
I am happy to be contacted by email
Please do not contact me about my membership*

Would you like to be included in the public register?

Yes
No

* 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.

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