Membership registration form

Please complete the following sections. The data will only be used to contact you about Lancashire Teaching Hospitals NHS Foundation Trust or health issues, and will be stored and processed in accordance with the Data Protection Act.

Title

First Name

Surname

Address

Postcode

Telephone Number

Email

Prefered method of communication

Gender

Date of Birth

Type of membership
Public - Anyone who lives within the boroughs of Chorley, Fylde (the Kirkham area), Ribble Valley (the Longridge and Ribchester areas), South Ribble, Wyre (the Garstang area) and the City of Preston
Patient - Anyone who has been a patient or has received any healthcare from Lancashire Teaching Hospitals in the last three years.

Ethnic group