Tel: 0845 026 4418
Fax: 01626 888360

Patient Participation Group - Sign up for the Patient Survey
Dear Patient

The doctors and staff at the Barton Surgery are keen to hear your views and opinions of the service we provide.

One of the ways we have thought of to engage with people is to set up a virtual patient representation group. We are keen to encourage people to have their say and, if you agree to take part, we will be asking you questions from time to time about our service and will contact you via email with short surveys.

To keep the group fully representative of our patient population, we need as broad a spectrum as possible; young people, workers, retired people, young mums, carers, patients with long term conditions, people with disabilities, ethnic minorities, unemployed, etc.

If you would like to sign up to this virtual group please complete the form below and submit. We will contact you once it has been processed.

Thank you for your assistance.

Your Personal Information
*	Title:	Mr Mrs Miss Ms
*	First Name(s):
*	Surname:
*	Email Address:
*	Telephone:
*	Postcode:
To ensure that the information we receive is from a broad spectrum of patients, please complete the details below:
Your Gender:		Male Female
Your Age:		Under 16 17-24 25-34 35-44 45-54 55-64 65-74 75-84 Over 84
The ethnic background with which you most closely identify is:
White:		British Group Irish
Mixed:		White & Black Caribbean White & Black African
Asian or Asian British:		Indian Pakistani Bangladeshi
Black or Black British:		Caribbean African
Chinese or Other:		Chinese Any Other
How would you describe how often you come to the practice?
Regularly Occasionally Very Rarely
The information you supply us 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 that this information is handled properly.