Join our PPG

We welcome enquiries from patients who would like to join our patient group.

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
Membership type
We have two types of PPG Membership, please indicate which type of member you wish to join as:
- 1. Face-to-face member Members that attend meetings (in person when permitted, or remotely via phone/Microsoft Teams). Are invited to take part in surveys and for their views when the surgery plans to make a significant change. F2F members may also hold a role within the PPG such as Chair or Secretary.
- 2. Virtual member Members who do not regularly attend meeting (although are very welcome to if they wish) but are kept up to date, invited to complete surveys and for their views when the surgery plans to make a significant change.
Thank you
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.
Phone
This field is for validation purposes and should be left unchanged.

Join our PPG

Additional information

Ethnicity

Membership type

Thank you