Patient Group

Dear Patient,

We would like to know how we can improve our service to you and how you perceive our surgery and staff.

To help us with this, we are setting up a virtual patient representation group so that you can have your say. We will ask the members of this representative group some questions from time to time, such as what you think about our opening times or the quality of the care or service you received. We will contact you via email and keep our surveys succinct so it shouldn’t take too much of your time.

We aim to gather around a hundred patients from as broad a spectrum as possible to get a truly representative sample. We need young people, workers, retirees, people with long term conditions and people from non-British ethnic groups.

If you are happy for us to contact you occasionally by email please complete the Patient Group Form at the bottom of this page.

If you prefer, you can download the sign up form as a pdf document, print it out, complete it and return it to the practice.

We will be in touch shortly after we receive your form. Please note that no medical information or questions will be responded to.

Many thanks for your assistance

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.

Fields marked with an asterisk are compulsory.

Title*
MrMrsMsDameDrProfSir

First Name(s)*

Surname*

Your Email*

Telephone*

Postcode*

Date of Birth*

Usual Surgery*

The Information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.

Your Gender*

Your Age*
Under 1617-2425-3435-4445-5455-6465-7475-84Over 84

The Ethnic background with which you most closely identify is:

British GroupIrishWhite & Black CaribbeanWhite & Black AfricanWhite AsianIndianPakistaniBangladeshiCaribbeanAfricanChineseAny Other

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

RegularlyOccasionallyVery Rarely

By submitting this form you indicate that you agree to the conditions below.

Please note that we will not respond to any medical information or questions received through the survey.
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.
Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.