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Patient Participation Group Form

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.

To help us ensure our contact list is representative of our local community please indicate which of the following ethnic background you would most closely identify with?



Asian / Asian British

Black / Black British

Chinese / other ethnic Group

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

Are you Interested in Joining?

If you are happy for us to contact you periodically by email please fill in the form on the left hand side.

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.