We are trying to put together a virtual patient participation group, to encourage patients to give their views about how the practice is doing. We are therefore asking if patients would like to provide their email addresses. This information will be used to contact you occasionally by email to ask you some brief questions.

Are you interested in leaving your email contact details?

If so, please complete the form below and we will add your email to our patient contact list. These details will only be used to contact you for this purpose and will be kept safely and separate to your medical records. You can ask for your details and email address to be removed at any point.

Name

e mail

Postcode

This additional information will help to make sure we are contacting a representative sample of the patients that are registered at this practice.

Age

Gender Male Female

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?

Ethnicity White British White Irish Mixed Race: White and Black Caribbean Mixed Race: White and Black African Mixed Race: White and Asian Asian or Asian British: Indian Asian or Asian British: Pakistani Asian or Asian British: Bangladeshi Black or Black British: Caribbean Black or Black British: African Chinese Other

How would you describe how often you come to the practice? Regularly Occasionally Rarely

We are planning our next annual survey and to ensure that we ask the right questions, we would like to know what you think should be our key priorities when it comes to looking at the services we provide to you and others in the practice.

What do you think are the most important issues on which we should consult our patients? For example, areas raised so far include:

Clinical care
Getting an appointment

Other areas you would like to suggest

Thank you.

Please note that we cannot respond to any clinical matters or questions received through this survey.

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