University Hospitals Birmingham NHS Foundation Trust

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Membership registration form

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)*

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?*

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

Please tell us your employment status:

If other, please state:

Are you male or female?*

Male
Female

If other, please state:

Are you registered disabled?*

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

Braille
Large font
CD-ROM

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*:*

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?*

* 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.

Spam protection. What is eleven minus two?*