Patient Participation Group Registration

If you are interested in becoming a member of the Patient Participation Group (PPG) or the Virtual Patient Group (VPG) please complete this form.

Patient Participation Group Registration

Patient Participation Group Registration

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Full Name: *

Postcode:

Phone Number:

Email Address: *

Any responses we send will go to this email address.

I am interested in becoming a member of the...

Patient Participation Group (PPG)

Virtual Patient Group (VPG)

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