Patient Participation Group (PPG) form

What is your name?

Title

First name

Middle name(s)This is an optional field.

Last name

Do you know your NHS or patient number?

NHS numberThis is an optional field.

Patient numberThis is an optional field.

What is your date of birth?

For example, 15 3 1984.

Day

Month

Year

What is your current postcode?

Postcode

Which of the following best describes how you think of yourself?

This is an optional question.

Female

Male

Non-binary

Prefer to self-describe

We collect this information to ensure that the PPG is as representative as possible of our practice population as a whole.

Which is your ethnic group?

Select one option

Asian or Asian British

Includes any Asian background, for example, Bangladeshi, Chinese, Indian, Pakistani.

Black African, Black British or Caribbean

Includes any Black background.

Mixed or multiple ethnic groups

Includes any Mixed background.

White

Includes any White background.

Another ethnic group

Includes any other ethnic background, for example, Arab.

Prefer not to say

We collect this information to ensure that the PPG is as representative as possible of our practice population as a whole.

How would you like to be contacted?

This is an optional question.

Phone number

Mobile number

Email address

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

Regularly

Occassionally

Very rarely

Privacy protection

Information submitted through this form is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

I consent to my information being used for the purposes described above and wish to submit this online form to Castlefields Surgery.

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Patient Participation Group

What is your name?

Do you know your NHS or patient number?

What is your date of birth?

What is your current postcode?

Which of the following best describes how you think of yourself?

Which is your ethnic group?

How would you like to be contacted?

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

Privacy protection

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