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Join our membership

Become a member
We want to hear your views, ideas and opinions to develop and improve healthcare services in Bedfordshire - whether you are a patient, member of staff or care for someone using NHS services.

* indicates a mandatory field

Title (Mr/Mrs/Miss/Ms/Dr) *
First name *
Family name *
Date of birth *
Name of business, organisation or group (if applicable) *
Address *
postcode *
tel (home) *
tel (work)
Mobile telephone number
Email:
Under which category would you like to join BCCG's membership scheme? *







please provide further details
Your health interests (please tick any that are of interest to you)








Is there any other area of health that you are interested in, not mentioned above? Please describe.
How would you like to be involved or consulted? (please tick all that apply)




BCCG has a large public membership and so our preferred method of communication is via email. If possible, we would be very grateful if you could please provide us with an email address in question 2.
Preferred method of contact? *

About you:
Are you: *

What is your age group? *







Do you consider yourself to have a disability? *

If yes, please specify nature of disability:



What is your ethnic group?
(A) WHITE:


(B) MIXED/MULTIPLE ETHNIC GROUPS


(C) ASIAN/ASIAN BRITISH



(D) BLACK/AFRICAN/CARIBBEAN/BLACK BRITISH

(E) OTHER ETHNIC GROUP
(F)
What is your sexual orientation?



    


 

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