Patient Reference/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 Reference/Participation Group Registration

Patient Reference/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