The practice has an active patient participation group. If you are interested in joining, please complete the form below.

Patient Participation Group Registration

Patient Participation Group Registration

If you are human, leave this field blank.

Full Name: *

Postcode:

Phone Number:

Email Address: *

Any 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

Do you give permission for the surgery to share your information with the PPGT committee? *

Yes

No