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Goyt Valley Medical Practice NHS GP Surgery in Whaley Bridge

Patient Participation Group registration

Patient Participation Group Registration

Section

Gender:

Male

Female

Other

Please specify: *

Participation confirmation:

I would like to be involved in the Patient Participation Group by attending meetings

I would like to be involved in the Patient Participation Group by receiving electronic information and providing online feedback

I am interested in being involved in patient / public engagement consultations or events

I consent to my contact details being shared with other members of the Group

I have a particular interest in the health and wellbeing area of:

Additional information

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

Regularly

Occasionally

Very rarely

Are you living with a long-term condition?

Yes

Are you living with a disability?

Yes

Are you a carer?

Yes

Which age group are you in?

Under 16

17 – 24

25 – 34

35 – 44

45 – 54

55 – 64

65 – 74

75 – 84

Over 84

Ethnic background:

White: British Group

White: Irish

Gypsy or Irish Traveller

Other White

Mixed: White & Black Caribbean

Mixed: White & Black African

Mixed: White & Asian

Other Mixed

Asian or Asian British: Indian

Asian or Asian British: Pakistani

Asian or Asian British: Bangladeshi

Asian or Asian British: Chinese

Other Asian

Black or Black British: Caribbean

Black or Black British: African

Other Black

Other Ethnic Group: Arab

Any Other

Please specify:

Signature: *

Enter full name

Date:

If you are human, leave this field blank.

Whaley Bridge Medical Practice
Chapel Street
Whaley Bridge
High Peak
SK23 7SR

Get directions

01663 735112

Chapel-en-le-Frith
Eccles Road
Chapel-en-le-Frith
High Peak
SK23 9EQ

Get directions

01663 735112

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