Join Today

The Patient Voice Panel is an exciting new way for you to work with NHS Walsall CCG to better understand and help to shape local healthcare services. There is also an opportunity to share your experience of using local healthcare services.

Membership is free and you can be involved as much or as little as you like. All we ask is that you have an interest in the NHS and a passion for making things better for Walsall.


Application Form

Title

First Name

Surname Name

Address Details

Address

Address 2

City/Town

Post Code

Further Details

Age

Do you consider yourself to have a disability?

 Yes No

If yes, please explain

Your GP practice:

Organisation you represent (if applicable):

Preferred Method of Contact (please tick below)

 Email (our preferred method of communication) Phone Post
If you said email or phone please give details below

Areas of interest (e.g. Asthma, Stroke) if applicable:

Gender

Ethnic origin

Asian

 Indian Pakistani Bangladeshi Any other Asian background (please specify below)

Black

 Caribbean African Any other Black Background (please specify below)

Chinese or other ethnic group

 Chinese Any other Ethnic group (please specify below)

White

 English Irish Scottish Welsh

European

 Any other European Background, for example Polish/ Bulgarian/ Russian/ Romanian (please specify below)

Specify here if you choose other

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 Please confirm that you have read and understood the data protection information

Download form here

 

The above details are requested to help us to monitor and ensure we are providing equal access to registration and appropriate engagement opportunities for people from all backgrounds and to enable us to support you with any access needs you may have.
Your details will be kept on a secure database and will only be used to contact you about the topics you have told us you are interested in. 

Your details will be held securely by Blue Step Solutions on behalf of Walsall CCG and will only be used by Blue Step Solutions and Walsall CCG for the purposes outline above.  Under the Data Protection Act you have the right to request the accuracy of any information we hold about you and you can request that it is removed from our database at any time.