We’re setting up a patient representative group to give us feedback on the range and quality of our services and tell us where we can improve.

Our aim is to reach a wide range of patients so we get views from across our population. To make it as easy as possible for you, it will be a virtual group. This means most of the communication will be through email and completing online surveys. However, we’ll make sure those without internet access can also take part.

How often will you contact me?

Not very often… approximately 2-3 times a year, plus an annual survey

If you are interested in having a say in the services we provide, please complete the Sign Up Form.  Alternatively, you can download a form from within our Documents section on the website.

Title:

Mr Mrs Miss Ms Dr Other

Forename *

Surname *

Date of Birth *

 Format: dd/mm/yyyy

Address *

Postcode *

E-mail address *

Mobile Phone Number

Phone Number *

Are you ? *

Male

Female

How old are you ? *

Under 16

17-24

25-34

35-44

45-54

55-64

65-74

75-84

Over 84

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

Regularly

Occasionally

Very Rarely

Are you a carer of one of our patients? .

Yes

No

Do you have any long-standing illness, disability or infirmity? By long-standing we mean anything that has troubled you over a period of time or that is likely to affect you over a period of time *

Yes

No

Which ethnic group do you belong to? *

White

Black or Black British

Asian or Asian British

Mixed

Chinese

Other Ethnic Group

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