Patient Participation Group Registration

All registered patients are welcome to join our digital patient participation group. If you are interested in receiving communications from the practice and invitations to help contribute towards the way the practice does things – please complete the form. You can opt out of the group at any time.

If you are human, leave this field blank.

First Name: *

Surname: *

Phone Number: *

Email Address: *

Are you:

Male

Female

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

Regularly

Occasionally

Very rarely

We are required to advise you of the information we hold about you, our purpose for holding it and when and how it gets deleted from our records.

For every registered PPG Patient who has completed and signed our registration form, we hold your Name, Telephone Number and Email Address.

Your information will be deleted within 3 months should you stop/cease to be a patient of the practice or you ask for it to be deleted.

Your details are kept by the PPG Secretary on a password protected database and will only be used for the purposes described above. Under no circumstances will your information be passed to a third party without your written consent.

Terms and Conditions *

I would like to be kept advised of the activities, events and general information relating to the work of the practice and it's Patient Participation Group

I agree that the PPG can hold the information above

Signature: *

Date:

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Patient Participation Group Registration

Patient Participation Group Registration

Self Help