Patient Participation Group Application Form

If you are happy for us to contact you occasionally by email, please complete the form below.

PP Group Application Form
Name
Name
First
Last
The following information helps us to ensure feedback is taken from a group of patients which represents the mix of patients registered with the practice.
Gender
Age group
Ethnic Origin

How often you come to the Practice?

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.