PPG Expression of Interest

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

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Your Gender:

MaleFemale

Your Age:

White

British groupIrish

Mixed

White and Black CaribbeanWhite and AsianWhite and Black African

Asian or Asian British

IndianBangladeshiPakistani

Black or Black British

CaribbeanAfrican

Chinese or other

ChineseAny other

How would you describe how often you attend the practice?

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.

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 Aitune.

The ethnic background you most closely identify with is:

Care Quality Commission

Gladstone House Surgery

CQC overall rating

Further Information