The Health Centre, Kents Bank Road, Grange-over-Sands, LA11 7DJ

Tel: 01539 715500 Out of Hours Information

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ONLINE PATIENT GROUP PARTICIPATION APPLICATION

We would love you to join this group; if you would like to do so please complete the details below:

Personal Details

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Your Gender

Your Gender

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Female

Your Age Group

Your Age Group

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16 to 24

25 to 34

35 to 44

45 to 54

55 to 64

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Your Ethnicity

Your Ethnicity

To help us ensure our contact list is representative of our local community please indicate which of the following ethnic background you would most closely identify with:

White British

Black, Black/British

White Other European

Chinese, Chinese/British

Your Ethnicity

Your Ethnicity

How would you describe how often you come to the practice?

Regularly

Occasionally

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Do you have any experience which you can draw on and bring to a role in the PPG, i.e., as a patient with a long term condition or disability, as a carer, or have you ever worked with the NHS in a professional or volunteer capacity?

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