Join our PPG We welcome enquiries from patients who would like to join our patient group. Patient participation group recruitment form Name*Email address* Enter Email Confirm Email Mobile number*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 rarelyHow would you like to be involved? (Please tick all that apply)Become a member of the PPG and attend meetings?YesNoFill in questionnaires by: Post Telephone Email Be kept informed of educational or other events or changes in the practice by: Post Telephone Email I would prefer to attend meetings in the: Morning Afternoon Evening Thank 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.CommentsThis field is for validation purposes and should be left unchanged.