PPG Sign Up Form
If you are happy for us to contact you by email from time to time, please complete this form.
Sign in to Google to save your progress. Learn more
Full Name
Email Address
Postcode
The information below will help to make sure that we receive feedback from a representative sample of patients registered at this practice.
Your Gender
Clear selection
Your Age
The ethnic background with which you most closely identify is
How often do you come to the practice?
Clear selection
How would you like to attend a PPG meeting?
Clear selection
Your information will be protected and will not be given to anyone else
Please note that we do 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 2018. The Data Protection Act 2018 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.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms