Join our PPG We welcome enquiries from patients who would like to join our patient group. Name*Email address* Post code*Additional informationThis 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?*MaleFemaleAge group*under 1617 - 2425 - 3435 - 4445 - 5455 - 6465 - 7475 - 84over 84EthnicityTo 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?What is your ethnicity?*White: BritishWhite: IrishMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and AsianAsian Indian or British IndianAsian Pakistani or British PakistaniAsian Bangladeshi or British BangladeshiBlack Caribbean or British CaribbeanBlack African or British AfricanAny other Black backgroundChineseAny other ethnic groupHow would you describe how often you come to the practice?*RegularlyOccasionallyVery rarelyConsentUnder GDPR (General Data Protection Regulations) the practice now need to gain your consent to pass your details onto the committee to allow them to contact you directly. You will only be contacted in connection with PPG business your details will not be shared. By ticking the buttons below you are consenting to us passing your contact details to the Chairman of the PPG to enable them to contact youPlease tick all that apply I consent to my contact details being forwarded to the PPG Chairman I am happy to be contacted by phone I am happy to be contacted by email I am happy to be contacted by letter Section BreakThank youPlease 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.EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
