Patient Participation Group (PPG) Application Form

All patients registered at Arlington Road Medical Practice, over the age of 16, are eligible to join. The group is limited to a maximum of 20 members. If you are interested in joining the group, please complete the form below. The PPG will contact you when a vacancy becomes available.

Last Updated: 20/01/2025

Your Contact Details

Title *

Surname *

First Name *

Date of Birth *

Address *

Telephone Number *

Email Address

About You

The information below will help us to make sure we receive input from a representative sample of the patients regsitered at this Practice.

Gender *

Age Group *

Which of the following ethnic backgrounds do you most closely identify with? *

How often do you attend the Practice *

Consent

This form will be submitted to the Practice and forwarded by the Practice to the Patient Participation Group.

I consent to the Practice forwarding my details to the Patient Participation Group for them to contact me *

I consent

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Arlington Road Medical Practice website

Patient Participation Group (PPG) Application Form

Further Information