ONLINE PATIENT GROUP PARTICIPATION APPLICATION

If you are happy for us to contact you periodically by email please enter your details below then click the Submit button.

Personal Details

Full Name Address Postcode Daytime Telephone Number Mobile Telephone Number Email Address

Your Gender

Male

Female

Your Age Group

Under 16

16 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 and over

Your Ethnicity

To help us ensure our contact list is representative of our local community please indicate which of the following ethnic background you would most closely identify with:

White British

Black, Black/British

White Other European

Chinese, Chinese/British

Your Ethnicity

How would you describe how often you come to the practice?

Regularly

Occasionally

Very rarely

Do you have any experience which you can draw on and bring to a role in the PPG, i.e., as a patient with a long term condition or disability, as a carer, or have you ever worked with the NHS in a professional or volunteer capacity?

Send Your Request

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