Patient Partner Form

A ‘Patient Partner’ includes patients, carers, family, and members of the public with an interest in cancer care.

If you are interested in making a difference to the way cancer services are run in north east London, become a patient partner to help inform and design our services.

Please complete the form below and someone from the Cancer Alliance will contact you.

Are you a patient or carer?

Please provide more information

First name

Last name

Address

Address 2

Borough

Postal Code

Email address

Contact number

Ethnic group

Contact method

If you are or were a patient, what type of cancer have you been diagnosed with?

Where did you receive your diagnosis and/or treatment?

Please provide additional information

Is there anything you would like to say about why you want to become a patient partner? – are there any skills or knowledge you can bring to this role?

The above is to test whether or not you are a human visitor and to prevent automated spam submissions.