Patient Reference Group

Would you like to join our on-line Patient Reference Group?

This means we would contact you from time to time to get your views on different aspects of our Practice.

Patient feedback is very important for us to continue to improve our services. If you would like to be included in the Reference Group please complete the following form. Your contact details will not be given out to anyone else and will be kept secure at all times.

Many thanks.

Patient Reference Group Registration - Thatcham

Patient Reference Group Registration - Thatcham

If you are human, leave this field blank.

Full Name: *

Date of Birth:

Please use this date format: DD/MM/YYYY

Phone Number:

Email Address: *

Responses we send will go to this email address

Are you:

Male

Female

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

Regularly

Occasionally

Very rarely

Ethnic Background:

White British

White Irish

White and Black Caribbean

White and Black African

White and Asian

Indian

Pakistani

Bangladeshi

Caribbean

African

Chinese

Other

Age group:

Under 16

17 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75 - 84

Over 84

Thank you very much for agreeing to participate in the Thatcham Medical Practice 'virtual' PRG.

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.

*

I confirm that I am currently within the UK at the time of sending my enquiry.