Gladstone Street, Ilkeston, Derbyshire, DE7 5QS | Tel: 0115 932 0248, Appointments :0115 850 8880

PPG Expression of Interest

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    • Expression of Interest for our Patient Participation Group.





    The information below will help to make sure we receive feedback from a representative sample of the patients registered at Gladstone.

    MaleFemale

    Under 1617-2425-3435-4445-5455-6465-7475 +

    The ethnic background you most closely identify with is:

    British groupIrish

    White and Black CaribbeanWhite and AsianWhite and Black African

    IndianBangladeshiPakistani

    CaribbeanAfrican

    ChineseAny other

    RegularlyOccasionallyRarely

    Thank you for expressing your interest to join our Patient Participation Group.

    Please note, no medical queries or information received via this form will be responded to.

    The information you provide us with 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 this information is handled correctly.