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Mythe Medical Practice NHS GP Surgery in Tewkesbury

Patient Participation Group registration

Patient Participation Group Registration

Please select one below: *

Mrs

Miss

Rev

Other

Please specify: *

Section

Home Address:

More about you

Please give us a little background information about yourself.

Ethnic Background: *

White British

White Irish

White and Black Caribbean

White and Black African

White and Asian

Indian

Pakistani

Bangladeshi

Caribbean

African

Chinese

Other

Age group: *

Under 16

17 – 24

25 – 34

35 – 44

45 – 54

55 – 64

65 – 74

75 – 84

Over 84

Do you have children of your own or care for children? *

Yes

How old are they? *

Are you a Carer? *

Yes

Have you had any connection with the medical world recently or in the past? *

Yes

Have you served on any committees? *

Yes

Why are you interested in becoming a PPG member? *

PPG meetings are usually held at 16:30, would this be a problem for you? *

Yes

Please provide a name and email address of a referee who may be approached if necessary. *

You are not required to complete a DBS check for this volunteer work.

Full Name in block capitals: *

Signed: *

Date:

If you are human, leave this field blank.

1st Floor The Devereux Centre
Barton Road
Tewkesbury
Gloucestershire
GL20 5GJ

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01684 293 278

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