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Patient Participation Group

We would like to know how we can improve our service to you and how you perceive our hospital, clinical care and staff.

To help us with this, we are setting up a virtual patient representation group so that you can have your say. We would like to ask the members of this representative group some questions from time to time, such as what you think about our range of services or the quality of the care you received. We will contact you via email and keep our surveys succinct so that particpation should not take too much time.

We aim to gather around a hundred patients from as broad a spectrum as possible to get a truly representative sample. We need young people, workers, retirees, people with long-term conditions and people from non-British ethnic groups.

If you are happy for us to contact you occasionally by email please complete and submit the form below. We will be in touch shortly after we receive your form.

Thank you in advance for your support.

Title

First Name(s) *

Surname *

Email Address *

Telephone *

Postcode *

Date of Birth (dd/mm/yyyy) *

Your Gender
MaleFemale

Your Age
Under 1617 - 2425 - 3435 - 4445 - 5455 - 6465 - 7475 - 84Over 84

The ethnic background with which you most closely identify is:
White - British GroupWhite - IrishMixed - White & Black CaribbeanMixed - White & AsianMixed - White & Black AfricanAsian or Asian British - IndianAsian or Asian British - BangladeshiAsian or Asian British - PakistaniBlack or Black British - CaribbeanBlack or Black British - A fricanChineseOther

How would you describe how often you come to the hospital?
RegularlyOccasionallyVery Rarely

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