We would like to know how we can improve our service to you and how you perceive our surgery and staff.

To help us with this, we are setting up a virtual Patient Reference Group so that you can have your say. We will ask the members of this representative group some questions from time to time, such as what you think about our opening times or the quality of the care or service you received. We will contact you via email and keep our surveys succinct so it shouldn’t take too much of your time.

We aim to gather around a hundred patients from as broad a spectrum as possible to get a truly representative sample. We need young people, workers, retirees, people with long term conditions and people from non-British ethnic groups.

If you are happy for us to contact you occasionally by email please complete all sections of the vPRG Sign-up Form below and submit.

If you prefer, you can download the sign up form as a pdf document, print it out, complete it and return it to the practice.

  Download the PDF version of our sign up form »

We will be in touch shortly after we receive your form. Please note that no medical information or questions will be responded to.

Many thanks for your assistance.

vPRG Sign-up Form

Please confirm you are a registered patient of the practice: Yes No
Full Name:
Date of Birth::
Email address:
Postcode:
This additional information will help us to select a representative cross section of the patients that are registered at this practice.
Are you?	Male      Female
Age group:	Please select... Under 16 17 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 Over 84
To help us ensure our contact list is representative of our local community, please indicate which of the following ethnic background you would most closely identify with?
Please select... White: British White: Irish Mixed: White and Black Caribbean Mixed: White and Black African Mixed: White and Asian Asian Indian or British Indian Asian Pakistani or British Pakistani Asian Bangladeshi or British Bangladeshi Black Caribbean or British Caribbean Black African or British African Any other Black background Chinese Any other ethnic group
How would you describe how often you come to the Practice?  Regularly       Occasionally        Very rarely
	Please type the red 6 letter word in lower case into the box below to reduce spam. Thank you. Spam reducer. Enter the word health.
Note: This will clear the entire form.

Thankyou.

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.