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During the workshop we'll be discussing what you think about talking with your doctor and your thoughts on technology and healthcare in general. This form will help us to make sure we have the right mix of people and ensure that you are aware of the ethics if you get involved.

Please answer as many questions as possible and we'll get in touch with you if we are able to include you in the activities.

Organisations involved in this workshop include Nuffield Department of Primary Care Health Sciences, University of Oxford and Design Science Limited.

We will not share your name in any published works or share your contact details with any other organisations. We will not connect any information you share with your identity or contact details.

Email *

1. What is your full name? *

I agree to participate voluntarily in these workshops and give my consent freely. *

Yes

I am happy for you to take photos and videoclips during the workshop and use things that I say or make during the workshop in future publications. *

Yes

Are you free to attend a workshop on either or both of these dates? *

Thu 12 December 9.30–11.30am

Thurs 23 Jan 9.30–11.30am

Not available on either date

Required

We can offer you £40 per workshop to cover your time and costs of getting to the venue. Are you happy with this? *

Yes

Can we contact you later to arrange a follow on conversation or visit? *

Yes

Tell us a little about you. What you do, your likes, frustrations, hopes and concerns? *

Background Info about you *

Female

Male

Non-Binary

Prefer not to say

Required

Age *

under 25

25 to 34

35 to 44

45 to 54

55 to 64

65 or over

Required

Ethnicity *

Arab

Asian

Black/ African/ Caribbean

Mixed/Multiple ethnic group

Other ethnic group

White

Prefer not to say

Required

Knowledge of English *

Limited

Average

Good

Required

Household Income level *

under £20,000

Between £20 and £40,000

Over £40,000

Prefer not to say

Required

Please tell us about additional needs or health conditions that may be relevant to using video-conferencing with your doctor *

4. What do you know about using video conferencing in general? (eg skype, facetime etc) *

5. How do you feel about this technology? *

'I don't trust the technology'

'I fully trust the technology'

Why? *

6. Have you ever used video conferencing technology? If so tell us about your experience in more details. If not, how do you imagine the experience? *

Have you ever held a videoconference with your doctor or clinician? *

Yes

If yes, was this held with the NHS or a private provider?

NHS

Private health provider

Clear selection

7. In which situations do you think video conferencing with your doctor would be valuable for you? (eg: busy, hard to get to doctor etc) Please give examples below *

8. Do you have any hopes or concerns around video consulting for your healthcare? *

Send me a copy of my responses.

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