Harlestone Road Surgery

Patient Participation Group Form

Name:
Date of Birth:
Email:
Address:
Daytime Telephone Number:
Date of Application:

I would like to join the:

Patient Participation Group	Yes			No
Patient Reference Group	Yes			No

Your help in completing the following would be appreciated, so that we can make sure all our groups of patients are represented as far as possible

Are You?

Male

Female

Age Group

Under 16		55 - 64 yrs
17 - 24 yrs		65 - 74 yrs
25 - 34 yrs		75 - 84 yrs
35 - 44 yrs		Over 84 yrs
45 - 54 yrs

Ethnic Origin - I would describe my ethnic origin as follows: (please tick as appropriate)

White
British Group
Irish
Mixed
White & Black Caribbean
White & Black African
White & Asian
Asian or British
Indian
Pakistani
Bangladeshi
Black or Black British
Caribbean
African
Chinese or other Ethnic Group
Chinese
Any Other

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

Regularly
Occasionally
Very rarely

To get us started - Ideas/Suggestions/Comments

 

 

Please note:

• No medical information or questions will be responded to.
• Individual complaints cannot be dealt with through the Patient Group.

Complaints should be addressed to the Practice Manager.

Copies of our complaints procedure can be requested from the practice.

Please be assured that your contact details will be kept safely and securely, and not shared with anyone else.
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.