Patient Participation Group Registration

All registered patients are welcome to attend any meeting of the Patient Participation Group without giving prior notice. If you are interested in hearing about the activities of the Patient Participation Group but cannot/do not want to attend meetings please complete the form below to receive newsletters and invitations to contribute to the group activities online.

Please Note – once you have submitted this information, any reply or acknowledgement from us will be sent to the email address you provide at top of the form. This response may include personal and sensitive information about you. We therefore strongly advise that you provide a personal email address that only you have access to. If you do not wish for us to communicate with you via email, please do not use this form and call us instead.

Patient Participation Group Registration

Patient Participation Group Registration

If you are human, leave this field blank.

Full Name: *

Postcode:

Phone Number:

Email Address: *

This email address will be used for all correspondence relating to this request. Please be aware that if anyone else has access to this email address that they may see responses sent to you.

Are you:

Male

Female

How would you describe how often you come to the practice?

Regularly

Occasionally

Very rarely

Ethnic Background:

White British

White Irish

White and Black Caribbean

White and Black African

White and Asian

Indian

Pakistani

Bangladeshi

Caribbean

African

Chinese

Other

Age group:

Under 16

17 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75 - 84

Over 84