Patient Participation Group Registration of Interest

If you are interested in attending a meeting or getting involved in the activities of the PPG then please complete this short registration of interest. The Practice Manager will pass your details on to the PPG Chair and Deputy Chair who will follow this up with you.

Patient Participation Group Registration of Interest

Patient Participation Group Registration of Interest

If you are human, leave this field blank.

Full Name: *

Postcode:

Phone Number:

Email Address: *

Any responses we send will go to this email address.

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

If you have any relevant experience or areas of interest which may be useful for a PPG, then please provide this information below.