Signing Up For Patient Reference Group

If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.

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.
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 how often you come to the practice?
Code of Conduct
It is important that the Patient Participation Group represents all patients and does not become a place to air personal grievances. Therefore we would ask that you read and agree to our Code of Conduct for the Group.

I have read and agree to abide by the PPG Code of Conduct
 
  

About This Form

Fields marked with a red asterisk are
compulsory.

Thank you very much for working with the Practice. 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.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.