Patient Reference Group Application Form

If you are happy for us to contact you periodically by email, please complete the form below.

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