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We provide a comprehensive information, support and advocacy service for people affected by lung cancer throughout the UK.

Patient/Carer Registration Form

Personal Details:

Name:
Date of Birth:
Address:
Daytime Tel No:
Mobile No:
Email:
Patient Group:
(if applicable)

Lung Cancer Experience:
Current Lung Cancer Patient
Previous Lung Cancer Patient
Relative/Friend
When were you diagnosed?
Type of lung cancer?

What symptoms, if any, did you have?
Type of treatment received
Follow-up support or treatment received (if applicable)
What are your views on lung cancer care?
Please give some background information about yourself, for example, marital status,
family,work
Do you have any other comments about your experience?
Do you have any strong views on smoking and/or passive smoking? (if yes what are they?)
Do you have any views on screening for lung cancer?
Do you have any comments or views regarding lung cancer in general?

Media:

Would you be interested in speaking to the media?
Yes
No

Type of Contact:

 Television - interview (giving name)
Television - anonymous interview
Newspaper - interview (giving name)
Newspaper - anonymous interview

Radio - interview (giving name)
Radio - anonymous interview
Have you any experience in speaking to the media?
Yes
No
Would you be interested in receiving media training?
Yes
No

The charity will always contact you first for permission, regardless of whether you indicate on thisform that you are willing to participate. You will never be contacted directly by the media. Anynames will be kept in strictest confidence and will not be given out, prior to receiving the consentfrom individuals, at the time the media contact us.

User Involement:

Would you be interested in representing the views of people affected by lung cancer by sitting on a NHS health planning committee?
Yes
No
Do you currently sit on any NHS health planning committees?
Yes
No
(if yes, please give details)
Have you any experience of sitting on a committee?
Yes
No
Would you be interested in receiving user representative training?
Yes
No