The information that you provide on this form will be used by Wolverhampton CCG to contact you about local health care services/activities and to inform you of the ways in which you can get involved. We will also inform you of events being run by our partner agencies. If after registering it is found that you live within the boundaries of a different CCG, then your details will be forwarded on to that CCG. Midlands and Lancashire CSU help manage the Patient Partners scheme along with the CCG and will have access to your data. Your details will only be used for this purpose and will not be shared with anyone else.

The information you supply will be held securely and in accordance with the Data Protection Act 1998. You can opt out of the Patient Partners scheme at any time by contacting the Communications and Engagement team on 01902 444878. We will contact you for your consent if there are any changes to the way in which your information is used.



















Ethnicity:








Gender:

Are your day to day activities limited by a health problem or disability which has lasted or is expected to last over 12 months?





Tell us what areas you are interested in:





















How would you like us to keep in touch with you?




How would you like to be involved? Please select all that apply: