Patient/carer membership form

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Patient/carer membership form

Please read our Guide to KPIN Membership before completing this form.

The confidentiality of your personal information is of paramount concern to us. KPIN will treat your details in confidence and in accordance with current data protection laws. For more information on how we use and store your data, see our Privacy Policy

Please note this form is intended for patients/carers only. If you are a professional, please use the professional membership form.

* indicates a compulsory field

Contact details

1. Name*

2. Email *

Please tick here to confirm that we can contact you by email: * You can unsubscribe at any time by emailing info@KPIN.org.uk

About you

Any data you enter below will only be used to provide you with appropriate information resources and opportunities, as detailed in our Guide to KPIN Membership

3. Gender *

4. Date of birth (YYYY-MM-DD) *

5. Ethnicity *

7. Social media usage (Select all that apply)

8. I am a ... *

9. Kidney patient experience * (Select all that apply)
Not yet on treatmentAdvanced kidney diseaseUnit haemodialysisHome haemodialysisPeritoneal dialysisTransplantAs a carerOther (please describe)

10. My experience includes: * (Select all that apply)
Informal patient/carer representative in hospital (e.g. advocate/peer supporter)Patient or carer representative in Kidney Patient AssociationPatient or carer representative with a national charityPatient or carer representative on local renal unit or hospital committeePatient or carer representative in local, national kidney project, programme or committeePatient or carer representative in policy committee (such as NICE guidelines group)NoneOther (please describe)

11. Location *

12. Main kidney unit *

What would you like us to email you about?

13. I would like to receive information on: * (Select all that apply. You can contact us to change this at any time)
KPIN training/eventsJoining a committee/local kidney patient associationPeer supportProduct design feedbackQuality improvementResearch projectsService delivery/policy reviewVolunteering for a renal unitOther (please describe)

14. Would you like to receive the monthly KPIN newsletter? *

15.

KPIN is funded by Kidney Care UK

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