Dorset Clinical Commissioning Group

The Health Involvement Network

We want you to help us shape your local NHS services. We want to listen to your views and experiences to help us build better health care services in Dorset. 

Please fill out the details below to receive our quarterly newsletter and to be informed about opportunities where you can get involved. 

Section 1 Your Contact Details

Section 2 About You

This information will help us to ensure that we are talking to a wide range of people.

What is your age range?
 
 
 
 
 
What is your marital status?
 
 
 
 
 
What is your ethnic origin? White
      
Asian or Asian British
    
Black or Black British
   
Multi-Cultural
    
Other Ethnic Group
     
 
 
What is your religion or belief?
 
 
 
 
 
 
 
 
 
 
Which best describes your sexuality?
 
 
 
 
 
Do you consider yourself to have a disability?
 
 
 

Section 3 Additional Information

 
 
 
 
Your level of involvement
 
 

Section 4 Areas of Interest

To allow us to target our engagement more effectively, please indicate if you have any specific areas of interest below - you can update these at any time by contacting us.

 
 
 
 
 
 

Planned care - services and treatments which are not carried out in an emergency, often patients will be referred by their GP.

Specialised care - services and treatment that are provided by relatively few centres as they require specialist care/treatment.

For example: vascular surgery, physiotherapy, specialist cancer treatments, specialist eye healthcare, treatment of some skin hair and nail conditions etc.

 
 

For example dementia, cancer, diabetes, stroke, neurological (e.g. epilepsy), cardiac (relating to the heart e.g. atrial fibrillation).

 
 
 
 

Data Protection Act

I agree to allow the personal data I have supplied to be collected by NHS Dorset Clinical Commissioning Group (CCG) and to be used to send me relevant communications that I have expressed an interest in.

Dorset CCG is committed to protecting your privacy. We will only use the information collected lawfully, in accordance with the Data Protection Act 1998, and for the purpose for which you have supplied it. We will not share your personal data with any other organisation without your consent.

We will hold your information securely and it will only be accessed by staff from Dorset CCG.

 
 

If you no longer wish to receive future communications you can opt out at any time by emailing involve@dorsetccg.nhs.uk or by calling 01202 541946.

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