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 Participaton 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.

Patient Participation Group Registration

Patient Participation Group Registration

If you are human, leave this field blank.

Full Name: *

Date of Birth:

Please use this date format: DD/MM/YYYY

Phone Number:

Email Address: *

Responses we send will go to this email address

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

Would you be willing to join our PPG (Patient Participation Group)?

Yes

No

Would you like to receive the minutes of our meetings via email?

Yes

No

Would you like to receive our PPG newsletter via email?

Yes

No

Would you be interested in joining the 'virtual' PRG (Patient Representation Group), where you could contribute electronically?

Yes

No

Do you have a special interest in a particular medical condition?

Yes

No

Please provide details:

Are there any issues you would like to see on the agenda?

Yes

No

Please provide details:

*

I confirm that I am currently within the UK at the time of sending my enquiry.