Patient & Public Involvement Registration Form (Research)

Your contact details and some questions about you
Please fill it in only if you want to be contacted by post
Best way to contact you
Please tick one only
Are you
Please tick one only
(Please also indicate time of diagnosis) (Please note that this information is not mandatory)
Please note that this information is not mandatory
Please note that this information is not mandatory
Your agreement and preferences
Your agreement
Your preferences
Please indicate your agreement and initial preferences about your involvement. You may change these preferences or stop your involvement at any time (please tick all that apply).
Some more details about you
Do you consider yourself to be disabled? Under the Equality Act 2010 a disability is described as a physical or mental impairment which has a substantial and long term adverse effect on a person’s ability to carry out normal day-to-day activities.
We would like to ask you some more details about you. We collect this information to ensure that we involve people from across the entire spectrum of our patients, carers and members of the public. We may also use this data to identify people who may have experience of or a special interest in certain areas of research from time to time, e.g. younger women with ovarian cancer for a study for ovarian cancer. Please note that this information is not mandatory.
This data will be used only for the purpose of contacting you about your involvement/engagement activity at The Royal Marsden. Your data will be protected and stored on The Royal Marsden’s secure system. The only people to have access to your data will be the Patient and Public Involvement team; your data will not be shared with anyone else without your permission. Being involved or not in any research activities will have no effect on any care or future care you may receive. You can request to have your data erased at any time by contacting us on the email address below. By submitting your data you indicate your agreement to the above statements.