Join our Virtual Patient Participation Group (VPPG)

Full Name*
Email Address*
Post Code*
Your Branch Surgery*
Additional Information
This additional information will help to make sure we try to speak to a representative sample of the patients that are registered at this practice
Are you?*
Age Group*
Ethnicity
To help us ensure our contact list is representative of our local community please indicate which of the following ethnic backgrounds you would most closely identify with?
Your Ethnicity
How would you describe how often you come to the practice?
Thank You
Please note that no medical information or questions will be responded to. The information you supply us will be used lawfully, in accordance with the Data Protection Act .The Data Protection Act 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.

Additional Information