Virtual Patient Participation Group

All registered patients are welcome to join this group. Please complete the form below to receive our quarterly  newsletters and occasional survey.

Patient Participation Group Registration

Patient Participation Group Registration

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.

Date of Birth: *

Are you:

Male

Female

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

Regularly

Occasionally

Very rarely

Please tick your preference: *

Via email - please ensure you complete the email box above

Via post - we will use your registered address

Checkboxes

I understand that I can opt out at any time by notifying you and there is no further obligation