PATIENT PARTICIPATION GROUPPATIENT REFERENCE GROUP WOULD YOU LIKE TO

ISSUE 4 DEAR PATIENT WELCOME TO
PATIENT DATA FORM FOR ADULTS (AGED 15
PATIENT GUIDE TO ACL INJURIES WHAT IS

PATIENT HISTORY NAME AGE DATE 1 DESCRIBE
PATIENT ID NUMBER PATIENT NAME INFORMED CONSENT
PULMONARY REHABILITATION COMMUNITY REFERRAL PATIENT NAME………………………………NHS

Would you like to have a say about the services provided at [insert name of practice]






PATIENT PARTICIPATION GROUP/PATIENT REFERENCE GROUP



Would you like to have a say about the services provided at Bewbush Medical Centre.


We would like to hear your views.


By providing your e-mail details we can add them to a contact list that will mean we can contact you by e-mail every now and again to ask you a question or two.


Alternatively Bewbush Medical Centre now has a Patient Participation Group (PPG) who meets regularly, but we would like to expand the input to this group to include a wider cross section of our patient. 


Fill in the details on the reverse side of this leaflet and hand it back to reception or post it into the prescription box in the front foyer and we will add your e-mail address to a contact list.

Are you interested in: Patient Participation Group PATIENT PARTICIPATION GROUPPATIENT REFERENCE GROUP WOULD YOU LIKE TO Patient Reference Group PATIENT PARTICIPATION GROUPPATIENT REFERENCE GROUP WOULD YOU LIKE TO



Name:

Address:

E-mail address:

Postcode:


This additional information will help to make sure we try to speak to a representative sample of the patients that are registered at this practice.


APATIENT PARTICIPATION GROUPPATIENT REFERENCE GROUP WOULD YOU LIKE TO PATIENT PARTICIPATION GROUPPATIENT REFERENCE GROUP WOULD YOU LIKE TO re you? Male Female


Age: Group

Under 16


17 – 24


25 – 34


35 – 44


45 – 54


55 – 64


65 – 74


75 – 84


Over 84





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 Group


Irish




Mixed






White & Black Caribbean


White & Black African


White & Asian


Asian or Asian British






Indian


Pakistani


Bangladeshi


Black or Black British






Caribbean


African




Chinese or other ethnic Group






Chinese


Any other





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


Regularly


Occasionally


Very rarely



Thank you for completing this form.


Please note: no medical information or questions will be responded to.


The information you supply 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 that this information is handled properly.


TREAT PATIENTS IN A CLEAN AND SAFE ENVIRONMENT
0 INTERMITTENT POSITIVEPRESSURE BREATHING EFFECTS IN PATIENTS WITH HIGH
1 ASSIST IN THE PREPARATION OF PATIENTS FOR OPERATIVE


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