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Patient Reference Group

We would like to know how we can improve our service to you and how you perceive our surgery and staff. 

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To help us with this, we are setting up a virtual patient representation group so that you can have your say. We will ask the members of this representative group some questions from time to time, such as what you think about our opening times or the quality of the care or service you received. We will contact you via email and keep our surveys succinct so it shouldn’t take too much of your time.

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We aim to gather around a hundred patients from as broad a spectrum as possible to get a truly representative sample. We need young people, workers, retirees, people with long term conditions and people from non-British ethnic groups.

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If you are happy for us to contact you occasionally by email please complete the sign-up form below.

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We will be in touch shortly after we receive your form. Please note that no medical information or questions will be responded to.

 

Many thanks for your assistance

If you prefer, you can download the sign up form as a pdf document, print it out, complete it and return it to the practice.

Download the pdf version of our sign up form

Signing Up For Patient Reference Group

Your Details
Title
The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.
Your Gender
Your Age
The ethnic background with which you most closely identify is:
How would you describe how often you come to the practice?
Please choose an option
Please note that we will not respond to any medical information received through the survey.

Thanks for Signing Up to the Patient Reference Group.

Note that by using this form, you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your comment.

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Your IP address will be sent with your communication. In rare cases where abuse or criminal activity can be shown to have taken place this may be used by the authorities to trace you.

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