Patient Participation Group  Sign Up Form
Patient Participation Group Sign up form
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Email *
Title *
First Name *
Last Name *
Date of birth *
MM
/
DD
/
YYYY
Phone Number *
The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this Practice.
Your Gender
 *
Your Age
 *
Your ethnic background
 *
You attend the Practice
 *
Would you like to be an active member or just emailed information about the PPG activities? *
Happy to be emailed by the PPG?
 *
If you could change one thing at the Practice what would it be?
 *
Why would you like to join the Harefield Practice PPG?
 *
Privacy Policy
This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS.
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