Hammersmith and Fulham CCG Patient and Public Engagement Network

Thank you very much for taking an interest in joining NHS Hammersmith and Fulham Clinical Commissioning Group’s patient and public engagement network. H&F CCG is a GP-led organisation, which plans and buys (commissions) health services for the people living in Hammersmith and Fulham. It is our ambition to involve people meaningfully in every element of our work, which is why we are delighted to have your interest. We are asking for your contact details so that we can add you to our secure stakeholder database and contact you should an involvement opportunity arise which matches your areas of interest. We will only use the information collected for the purpose stated above. You can withdraw your consent for us to hold your information at any time by contacting us on hafccg.engagement@nhs.net / 0203 350 4303.

Question Title

* 1. Full Name

Name

Address

Address 2

City/Town

Postal Code

Email Address

Phone Number

Question Title

* 2. Areas of Interest: please put X in the box of those areas which interest you.

GP and Primary Care

Urgent and Emergency Care

Mental Health Service for People under 18 year aged

Mental Health Service foe People over 18 year aged

Services for People with Long Term Conditions

Musculoskeletal Health Service

Older People's Health Care

Diabetes

Alcohol and Drug Services

Sexual and Reproduction Health Service

Maternity Health Service

Children and Young People's Health Care

Cancer Screening Services

Health Services for People with Learning Disabilities

Health Services for People with Physical Disabilities

Access to Services for Carers

Dementia Care Service

Homeless Health Services

End of life Care

Other (please specify)

Question Title

* 3. Do you have any particular requirements that might affect your involvement? (e.g. Diet, Child Care, disabilities, access requirement)

Yes

Hammersmith and Fulham CCG Patient and Public Engagement Network

Question Title

* 1. Full Name

Question Title

* 2. Areas of Interest: please put X in the box of those areas which interest you.

Question Title

* 3. Do you have any particular requirements that might affect your involvement? (e.g. Diet, Child Care, disabilities, access requirement)

Question Title

* 4. If yes, please state what support or adjustments we can make to meet these requirements