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Virtual Panel
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We are reviewing our database to check its correct would you kindly take the time to fill out the information below.
Join the Virtual Panel
Contact details and personal information
Name
Title: (e.g. Mr. Mrs. Ms. Dr. Rev. etc)
Gender
Male
Female
Email address
Mobile telephone number
Address
Please type here
Postcode
For our research purposes it helps us to know more about you, please would you tick the relevant boxes as to how you would identify yourself (or the organisation, club, group etc) from the list below? Please tick all boxes that are of relevance to you.
Physically disabled (or representing)
Learning disabled (or representing)
Have mental health problems (or representing)
From a gypsy and traveller community
Lesbian, gay, bisexual or transgender
Older person (or representing)
Young person (or representing)
White British, Irish
Black and minority ethnic (BME) group/s
A carer (or representing)
A dependant (or representing)
From a religious or faith group (or representing)
On a low income or unemployed (or representing)
An asylum seeker or refugee (or representing)
Prisoner or ex-offender (or representing)
Sex industry worker (or representing)
Asian British, Asian
Your age group
Select an Item
--------------
16-25
25-40
40-50
50-65
Over 65
Brief summary of your organisation (if applicable)
Please type here
To help us send only the information you might be interested in please indicate which healthcare issues you have experience of or an interest in:
Elective care
End of life care
Cardiac care
Cancer
Children's health
Musculoskeletal
Women’s health
Head and neck
Carers
Dental
Skin (dermatology)
Long term conditions
Therapies
Stomach (gastroenterology)
Diagnostics tests
Neurosciences
Diabetes
Lungs and respiratory
Urgent care and emergency services
Maternity and birth
Preventative health and wellbeing (obesity, smoking, alcohol, sexual health)
Mental health and wellbeing
Older people’s care
Dementia
Pharmacy
Community services
Primary care GPs
Transport
Please tick your preferred method(s) of receiving information from us: we would prefer to communicate via email and/or SMS text message if possible.
By email
By SMS text (text message sent to a mobile phone)
By post
Please indicate if you would be willing to share information
Yes
No
If 'yes', please indicate who your regular contacts are:
Please type here
How will you share information with your regular contacts?
By email
By phone
By letter
Face to face meeting
Newsletter
Other (please state below)
Other
Thank you for working with us on improving healthcare
All of your details will be kept in a confidential database in keeping with the data information act.
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