Patient Participation Group Form – St Augustine's Medical Practice

First Name(s)

Surname

Email Address

Telephone

Postcode

Availability

Day time

Evening only

Monday

Tuesday

Wednesday

Thursday

Friday

Level of Engagement

How do you wish to get involved in the PPG?

PPG Chair

PPG committee

Occasional

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

Regularly

Occasionally

Very Rarely

Age

The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.

Under 18

18-64

65 and over

The ethnic background with which you most closely identify is:

Consent for storing submitted data

Join the Patient Participation Group