Sign up for the Patient Survey

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

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.

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.

If you are happy for us to contact you occasionally by email please click the link below to open the sign-up form and complete all the fields.

PRG application

Patient Reference Group

Title
Name
DD slash MM slash YYYY
The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.
Gender
Age
The ethnic background with which you most closely identify is:
White
Mixed
Asian or Asian British
Black or Black British
Chinese or Other
How would you describe how often you come to the practice?
Please choose an option

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

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