Patient Participation Group

Patient Paticipation Group Application Form

The Patient Participation Group will be a voluntary formal group made up of the Practices Patients.
The Patient Participation Group is to help us conduct a survey of our patients in order that we may improve our services where possible.

Selection of candidate will be made to ensure a fair representation of the Practice Population.

If you would like to apply to join the Patient Participation Group please complete the form below:

Name:

Telephone No:

Address:

Email Address:

Are you able to commit to
attend four meetings per year

*If you are happy to be periodically contacted by email then please add your email address.

The following addtional information will help us make sure we try to involve a representative sample of the patients registered at the practice.

Are you:

Male

Female

Please tick if you are a carer

A carer is a person who spends a significant proportion of their life caring for a relative, partner or friend who is ill, frail, disabled or has a mental health problem.

To help us ensure that our contact list is representative of our local community please indicate which of the following ethnic background you most closely identify with:

White

Black Caribbean

Black African

Black Other

Mixed

Indian

Pakistani

Bangladeshi

Other Asian

Chinese

Other Ethnic Group (Please state)

Patient Survey 2012

We are in the process of creating a survey for our patients which we will be conducting in the early months of next year.
We believe that it is very important for all of our patients to have their say about the services that we provide and to
make suggestions for ways in which we can improve.

As such we want this survey to ask the questions that you want answers to.
We would be grateful if you could provide any suggestions that you have for areas that we could address in form below:

Comments/Suggestions: