DDUH Patient Forum Committee

Calling All Patients

Thank you for your interest in joining the DDUH Patient Forum. This forum aims to give patients a voice in shaping services, improving care, and contributing to hospital developments.

All information provided will be treated confidentially and in line with data protection regulations.

Section 1: Personal Details

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* 1. Full Name:

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* 2. Date of Birth:

Date

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* 3. Contact Number:

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* 4. Email Address:

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* 5. Home Address:

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* 6. Hospital Number (if applicable):

Section 2: Patient Status

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* 7. Are you currently an active patient at DDUH?

Yes

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* 8. If yes, which clinic/department do you attend?

Section 3: Interest in the Patient Forum

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* 9. Why are you interested in joining the Patient Forum?

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* 10. What areas of hospital services are you most interested in contributing to?

Patient experience

Communication & information

Accessibility

Facilities

Treatment services

Other (please specify)

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* 11. Do you have any previous experience in committees, groups, or forums?

Yes (please specify)

Consent

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* 12. I consent to my information being used for the purpose of contacting me about the DDUH Patient Forum.

I consent

DDUH Patient Forum Committee

Calling All Patients

Question Title

* 1. Full Name:

Question Title

* 2. Date of Birth:

Question Title

* 3. Contact Number:

Question Title

* 4. Email Address:

Question Title

* 5. Home Address:

Question Title

* 6. Hospital Number (if applicable):

Question Title

* 7. Are you currently an active patient at DDUH?

Question Title

* 8. If yes, which clinic/department do you attend?

Question Title

* 9. Why are you interested in joining the Patient Forum?

Question Title

* 10. What areas of hospital services are you most interested in contributing to?

Question Title

* 11. Do you have any previous experience in committees, groups, or forums?

Question Title

* 12. I consent to my information being used for the purpose of contacting me about the DDUH Patient Forum.

Question Title

* 13. Signature: ___________________________