PPG Signup

Would you like to have a say about the services provided at our Surgery?

We would like to hear your views. By providing your email details we can add them to a contact list that will mean we can contact you by email every now and again to ask you a question or two.

Alternatively you may like to sit on the new Patient Participation Group which will meet periodically at the Surgery to discuss issues and suggestions. Simply fill in the details below and we will add your email address to a contact list.

Please ensure that you complete all fields marked with an * otherwise the form cannot be sent.

Name*
email Address*
Enter EmailConfirm Email
Telephone Number*
Additional information
This additional information will help to make sure we try to speak to a representative sample of the patients that are registered at this practice.
Gender*
- Male
- Female
Age Group*
To help us ensure our contact list is representative of our local community please indicate which of the following ethnic backgrounds you would most closely identify with?
How would you describe your ethnicity?*
How would you describe how often you come to the practice?*
- Regularly
- Ocassionally
- Very rarely
Would you like to be part of the Patient Participation Group?
- Yes I would like to join the Patient Participation Group
Please note that no medical information or questions will be responded to. The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998.The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.
Name
This field is for validation purposes and should be left unchanged.

PPG Signup

Would you like to have a say about the services provided at our Surgery?

Additional information