Belgrave Medical Centre

PATIENT PARTICIPATION GROUP APPLICATION FORM

As a registered patient you would be very welcome to join our Patient Participation Group here at Belgrave Medical Centre

The PPG will meet approximately twice a year and hold educational events to help the surgery by offering their opinion on ways we can maintain our high standards as well as helping us with our annual Patient Survey.

We do understand that some patients may not wish to attend face to face meetings but instead would be willing to be involved by being contacted, occasionally, via e-mail, to answer questions about how well the surgery is performing and to identify any areas for improvement.

If you would be willing to join our Patient Participation Group, please complete the form below, identifying whether you wish to be considered to sit on our PPG or to be contacted to answer ad hoc questions, and return it to reception.

Your details will be used for this purpose only and will be kept confidential.

I would like to join the Belgrave Medical Centre Patient Participation Group
			
First name: (please print)	…….……………………………………………………..……………………………….

Surname: (please print:	……………………………………………………………………….………………………

Date of birth:		…………………………………………………………………………………………....….

E-mail address: (please write clearly) ……………………………………………………………….…………...

Please consider me for joining (please circle)

PPG

(PTO)

WHY ARE YOU INTERESTED IN JOINING THE GROUP? (Give a brief outline)

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WHAT QUALITIES COULD YOU BRING TO THE GROUP? (Give a brief outline)

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I give my consent for these contact details to be retained for use by Belgrave Medical Centre and the Belgrave Medical Centre Patient Participation Group.

Signed:	………………………………………..	Date:	………………………………………………………

Please hand in your completed form at reception.

THANK YOU