Patient and Community Engagement survey
1.
Full name
2.
Email address
3.
Phone number (with code)
4.
Preferred contact method
Phone
Email
5.
Are you registering as a:
Patient
Patient advocate
Community member
Healthcare professional
6.
Age group
Under 18
18-24
25-34
35-44
45-54
55-64
65+
7.
What is your current occupation or field?
8.
Do you work in healthcare or a related field?
Yes
No
9.
Do you have any prior experience serving on committees or initiatives?
Yes
No
10.
If yes, please provide brief description of your previous experience:
11.
Do you currently have any medicolegal issues or conflicts of interest involving Moorfields Eye Hospital Dubai?
Yes
No
12.
If yes, please provide a brief explanation:
13.
Are you available to attend committee meetings:
In-person
Virtually
Both
14.
How Often would you be able to commit to meetings and activities?
Weekly
Monthly
Quarterly
Semi - annually
As needed
Send me a copy of my responses via email
