Patient Participation Group registration

Which surgery do you normally attend? *

Mile End Surgery

Tuckswood Surgery

Gurney Surgery

Section

I have no objections to my email address being added to my medical record as a future form of correspondence. Please note, this will only be used for actions such as sending letters to you or reminding you of reviews and will not be used for any marketing purposes.

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

Regularly

Occasionally

Very rarely

Ethnic Background:

Age group:

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Patient Participation Group registration

Section