Patient Participation Group Sign Up Name First Last Date of Birth Day Month Year Email Enter Email Confirm Email Contact NumberGenderMaleFemaleOtherAgeUnder 1617-2425-3435-4445-5455-6465-7475-84Over 84Gender Other Security Question (used to identify you)Choose a questionIn which month did you last see a doctor/nurse at this surgery?Do you take any prescribed medicines? Can you tell me what they are?Have you had an operation in hospital? Can you remember when and what it was for?May be used to identify youAnswer The ethnic background with which you most closely identify is: How often do you come to the practice?RegularlyOccasionallyRarelyVery RarelyWhat can you bring to the Patient Group – Ideas / Suggestions / Comments OptionalPrivacy ConsentThis form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form.
