Accessibility
|
FOI
|
Privacy Policy
|
Browsealoud
|
Sitemap
|
Text Only
|
ARCHIVE ONLY - SITE NO LONGER LIVE
Search Box
How to use this site
Customise site
A
A
A
select a colour scheme for YOUR NHS Leeds website:
Home
Your local services
Your health
Have your say
Working for us
About us
News & media
Useful links
Contact us
Home
|
Have your say
|
Do you want to
|
Get involved or volunteer
|
Involvement Network Application
News
Do you have a
Comment
Concern
Compliment
Complaint
Do you want to
Ask a question
Have your say on public consultations
Archive of public consultations
Vascular Services Review
Morbid Obesity Surgical Services
Living well with dementia - your views
Government listening exercise
Get involved or volunteer
Take part in research
Getting involved in research
Register your interest
Come to public meetings
You said, we did
General advice and info
LEFT-COL-FEATURE-4
Involvement Network Application
Please complete the form below if you would like to register your interest in the NHS Leeds Patient, Carer and Public Involvement Network. Please ensure you complete any fields marked as required.
We will contact you as soon as possible after you have submitted your form.
Title
Dr
Mr
Mrs
Miss
Ms
Name (required)
Email (required)
Address (UK Style)
Address line 1
Address line 2
Town
Region
Country
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
England
Equatorial Guinea
Eritrea
Espana
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea (South)
Korea, Republic of
Kuwait
Kyrgyzstan
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Ireland
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Samoa (Independent)
San Marino
Sao Tome and Principe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Swaziland
Sweden
Switzerland
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
USA
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wales
Wallis and Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Postcode
Telephone
Mobile number
Date of Birth
Do you have any support needs to be able to attend meetings ie. interpreter?
There are a number of different areas that you may be interested in being involved in. Please tick the subjects below that you would like to be contacted about.
Cancer
Carers
Children & Families
Commissioning
Community Nursing
Dermatology/skin
Dentistry
Diabetes
GP practices/services
Heart conditions
Learning disabilities
Maternity
Mental Health
Neurological conditions
New technology
Older People
Ophthalmology/eyes
Pharmacy & medicines
Reading leaflets/papers (Reader Group)
Research/consultation Projects
Respiratory diseases
Sexual health
Strategic work (eg vision & values / organisational development)
Stroke
Urgent/emergency care
Please include any other topics you are interested in
Do you consider yourself to have a disability (required)
Yes
No
If you have ticked 'Yes' please indicate the nature of this disability
Ethnicity
White English
White Irish
White Scottish
White Welsh
White Other
White Irish Traveller
White Traveller
White Gypsy / Romany
Black African
Black Caribbean
Black Other
White and Black Caribbean
White and Black African
White and Asian
Chinese
Bangladeshi
Indian
Pakistani
Any other minority group
If none of the above categories define your ethnicity, please state how you would describe your ethnicity.
