Expert Patient Programme
Registration Form
Dear Participant
Our aim is to deliver the Expert Patient Programme throughout Cornwall. To register your
interest in the programme, can I ask you to please complete the form and send it back as soon
as possible to the address below.
Please inform me of the next available course in
my area. Please state area you can travel to.
Eg. Live in Bodmin but can travel to Redruth,
St Austell or Liskeard
Area:
Personal Details To be completed by participant
Title
Forename
Phone
number
Mobile:
Last name
E-mail
Address
Postcode
Emergency contact: If you have a CPN and would like to include their details below or a
family/friend to be used only in an emergency during the course:
Name
Phone number
Mobile
Individual needs
Please state your long-term condition or
conditions?
(e.g heart conditions, epilepsy, diabetes)
Do you have any special requirements?
Please specify:
Please note: If you are a wheelchair user and require assistance please bring an assistant
with you as we are unable to offer a personal care service.
Registration Form
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Your contact details are stored on the training services database for 18 months after you
have attended a course. This will enable us to contact you from time to time to keep you
informed of other courses and services and assist us with further evaluation of the courses
we offer. Peninsula Community Health does not pass this information on to any third party.
Please tick this box if you do not want Peninsula Community Health to store your
details after you have attended the course.
How did you find out about the Expert Patient Programme?
Please tick the appropriate box
Peninsula
Referral from a
Community Health
health professional,
web site
Please specify
Leaflets or Posters
Friend
Someone who has
attended
Other, please specify
If you were referred by a health professional
could you tell us what type of health
professional and which hospital/surgery they
are based?
Date enquiry was made to Expert Patient
Programme?
Thank you for completing the registration form
All this information will be treated as confidential
PLEASE RETURN THIS COMPLETED FORM AS SOON AS POSSIBLE TO:
ELAINE CURNO
EXPERT PATIENT PROGRAMME MANAGER
THERAPIES DEPARTMENT
LISKEARD HOSPITAL
CLEMO ROAD
LISKEARD
PL14 3XD
Any questions then please do contact me by phone or e-mail
Mobile: Elaine: 07824598626
Telephone: 01579 373500 and leave a message at Liskeard Hospital switchboard
E-mail: elaine.curno@pch-cic.nhs.uk
Registration Form
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