Join our PPGWe 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?* Male FemaleAge 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?* Regularly Occasionally Very 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 letterSection BreakConsent*By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website. I agree to the privacy policy.Thank youCommentsThis field is for validation purposes and should be left unchanged.
