Join our PPG – The Dicconson Group Practice

If you are interested in joining the group, please contact the practice via the contact details on this website, or by printing out the form contained in the survey report, and then drop this in at the practice.

We realise that not every person has access to the internet, and if you do require a hard copy of the survey report please contact us (copies are also displayed in the reception area.

Name*
Email address*
Post code*
Additional information
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.
Are you?*
- Male
- Female
Age group*
Ethnicity
To help us ensure our contact list is representative of our local community please indicate which of the following ethnic backgrounds you would most closely identify with?
What is your ethnicity?*
How would you describe how often you come to the practice?*
- Regularly
- Occasionally
- Very rarely
Do you consent for us to pass your information to the PPG Chair to contact you?
- Yes
- No
Thank you
Please note that no medical information or questions will be responded to. 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.
Name
This field is for validation purposes and should be left unchanged.

Additional information

Ethnicity

Thank you