Patient Participation Group

Dear Patient,

patient survey

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 click the link below to open the sign-up form and complete all the fields.

Complete the Patient Group Sign-up Form Online

Signing Up For Patient Reference Group

If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.

YOUR DETAILS

Name
DD slash MM slash YYYY

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

Your Age

The ethnic background with which you most closely identify is:

White
Mixed
Asian or Asian British
Black or Black British
Chinese or Other

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.

 Download the pdf version of our sign up form

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.