Patient Participation Group Sign up Form PPG Sign Up Title Mr MrsMissMsOther Title Name * Surname * Email * Postcode * 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. Gender * Male Female Other 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. The ethnic background with which you most closely identify is: * How would you describe how often you come to the practice? Regularly Occasionally Very Rarely 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 1998.The Data Protection Act 1998 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. By submitting the form, you give your consent for us to store your email address and send regular updates. If you need to change your email address, you must contact the Surgery and update your details. If you are human, leave this field blank. Submit
