Register for Practice Patient Group

Thank you for expressing an interest in our Patient Group.

Please fill in the form below and press submit. A member of your practice team will then contact you to confirm your membership of the group and to ask you on which issues you would like to be consulted.

At which practice are you a registered patient?
We would prefer to contact you by email. However, you may choose to be contacted by letter.
How would you prefer us to contact you?
Name
Email
Confirm email
Address Line 1
Address Line 2
Town/City
Postcode
About you

We would like to make sure that our Patient Group includes a wide variety of patients. Please tell us:
Your sex Male Female
Your age group
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
- White
- British
- Irish
- Any other white background
- Asian or Asian British
- Indian
- Pakistani
- Bangladeshi
- Any other Asian background
- Black or Black British
- Caribbean
- African
- Any other Black background
- Mixed
- White and Black Caribbean
- White and Black African
- White and Asian
- Any other mixed background
- Other ethnic groups
- Chinese
- Any other ethnic group (please specify)

Please note: the Patient Group cannot discuss individual medical concerns. If you have any questions at all about your own health or treatment, please speak to your doctor.

The information you supply us will be used lawfully, in according 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.

About you