Patient Reference Group Membership Form

Please complete this form if you would like to join our Patient Reference Group

We will keep you informed by email with regular bulletins of what is happening at the surgery and invite you to attend meetings/functions etc from time to time.

If you are happy for us to contact, you periodically by email please leave your details below and hand this form back to reception.

Name

Date of Birth

Postal Address

Post Code

Telephone Number

Email Address

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

Are You?

Age Group

To help us ensure our contact list is representative of our local community please indicate how you would describe your:

Ethnicity

Nationality

How would describe how often you come to the practice?

How would you describe your employment status?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Westbourne Medical Centre • North Ormesby Health Village, 7 Trinity Mews, North Ormesby, TS3 6AL.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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