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Become a patient representative

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Patient involvement
Become a patient representative

If you would be interested in becoming a patient representative to help inform our work in south east London, please complete the below form and a member of the team will be in touch.

Are you a patient or a carer? Required

Patient

Carer

Name Required

Year of birth

Address

Address 1

Address 2

City

Country

County

Postal Code

Email address Required

Contact number Required

Ethnic group Required

If you take part in other patient groups or NHS Improvement projects - please give details below

How would you like us to contact you? Required

E-mail

Phone

Post

How would you like to participate in SELCA projects? Required

Online (email)

Online (virtual events and meetings)

Phone

In-person

Please let us know if you have any particular areas of interest, professional background skills, or expertise you can further contribute with:

If you are a patient - what type(s) of cancer have you been diagnosed with?

Where did you receive your cancer diagnosis?

Guy's and St Thomas' NHS Foundation Trust

King's College Hospital NHS Foundation Trust

Lewisham and Greenwich NHS Trust

Other

Where do / did you receive your cancer treatment?

Guy's and St Thomas' NHS Foundation Trust

King's College London NHS Foundation Trust

Lewisham and Greenwich NHS Trust

Other

Have you used any of the treatment services listed below?

Surgery

Chemotherapy

Radiotherapy

Therapies (physiotherapy, mental health, etc)

Any other comments or things you want to tell us?

I agree to the privacy policy.

Our aim is to ensure that patients in South East London receive timely diagnosis, high quality treatment, excellent experience, and improved clinical and quality of life outcomes.

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