Buckland Surgery

01626 332813

Join our PPG

We welcome enquiries from patients who would like to join our patient group.

Join our PPG

Patient participation group recruitment form

"*" indicates required fields

Are you on Social Media?
Tick any that are relevant
Employment Status*
Preferred Meeting Time*
Specific Areas of Interest
Please feel free to tick all that may apply or leave blank

Additional information

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

Ethnicity

To help us ensure our contact list is representative of our local community please indicate which of the following ethnic backgrounds you would most closely identify with?
How would you describe how often you come to the practice?*

Thank you

Please note that no medical information or questions will be responded to. 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.
Consent*
This field is for validation purposes and should be left unchanged.