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Expression of Interest Form - Individual
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About you
1. Title (Ms/Miss/Mr/Mrs/Mx/Dr/Prof etc)
2. Name
3. Which age group do you belong to?
Under 18
18-24
25-34
35-44
45-54
55-64
65 and over
Prefer not to say
4. Gender
Female
Male
Prefer not to say
Prefer to self describe
Enter answer
5. Email address
6. Can we share your email address with:
Other Forum contacts?
MHRA staff, where relevant to the work of the Patient, Public and Stakeholder Engagement team?
Do not share my details
Choose no more than 2.
7. Contact Number (Mobile/Landline, if applicable)
(optional)
8. Where do you live?
England
Northern Ireland
Scotland
Wales
Outside the UK
9. Will you participate in the Forum in your own right as a
Carer?
Patient?
Patient advocate?
Other
Please specify
Choose no more than 3.
10. Please specify the health condition(s)/disease area(s) you have lived experienced for or are interested in for medicine(s) and/or medical device(s)
11. Are you affiliated to any patient/carer networks or research charities?
Patient/Carer Network
Research charities
Both
None
Other
Enter answer
