Join our PPG

We are looking to recruit new members

If you are interested in joining our PPG or want to find out more, email us direct on [email protected] or complete the form below or call the Practice Manager, Emma Chapman, on 01580 880790.

Patient participation group recruitment form

Name*
Email address*
Post code*
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.
Are you?*
- Male
- Female
Age group*
Ethnicity
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?
What is your ethnicity?*
How would you describe how often you come to the practice?*
- Regularly
- Occasionally
- Very rarely
Consent*
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which 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. The practice privacy policy can be viewed on this website.
I agree to the privacy policy.
Thank you
Comments
This field is for validation purposes and should be left unchanged.

Join our PPG

We are looking to recruit new members

Join our PPG

Additional information

Ethnicity

Thank you

Helpful links

Further Info