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Patient Participation Group registration

Patient Participation Group Registration
Confirmation *

How would you prefer to participate? *
What are your main reasons for joining the PPG? (Select all that apply)
How would you describe your health? *
Gender: *
Ethnicity: *
How often do you come to the practice? *
What is your age group? *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Do you consent to the practice collecting and storing your data from this form? *