Warning: session_start() [function.session-start]: Cannot send session cache limiter - headers already sent (output started at /home/countes/public_html/virtual-PRG-sign-up-form.php:2) in /home/countes/public_html/virtual-PRG-sign-up-form.php on line 5
Countesthorpe Health Centre - Patient Participation Group
Small TextMedium TextLarge Text

Patient Reference Group

Virtual PRG sign up form

If you are happy for us to contact you periodically by email please enter your details in the form below.
(* Denotes required fields).

* Full Name:
* E-mail:
* Postcode:

We collect and monitor the following information to ensure we are treating all people fairly and to help us identify any barriers that may need to be addressed.

* Sex:
* Age:
* Current Employment:
* Your Health:
* Ethnic Group:
A. White
British
Irish
Any other white background
B Mixed
White & Black Caribbean
White & Black African
White & Asian
Any other Mixed background
C. Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
D. Black or Black British
Caribbean
African
Any other Black background
E. Chinese or other ethnic group
Chinese
Any other ethnic group, please state
* How often do you come to the practice:
   

If you have an email address, we would like to invite you to join the Patient Reference Group. Your views will help us improve the services we offer. Members of the group will also receive information from us about the surgery and any relevant topics.

 

Q. Why are you asking people for their email addresses?

A.  We would like to be able to contact people occasionally to ask them questions about the surgery and how we are providing services so that we can identify areas for improvement. We would also like to inform patients as quickly as possible about matters such as health campaigns or opening hours during holiday periods.

 

Q.  Will my doctor see this information?

A. We will only contact you to ask your views about the surgery and ensure changes that are being made are patient-focussed.  If your doctor is responsible for making some of the changes in the surgery they might see general feedback from patients.

 

Q, Will the questions you ask me be medical or personal?

A.  No. We will only ask general questions about the practice. No personal or medical information will be exchanged via email and none of the information will appear on your medical record.

 

Q. Who else will be able to access my contact details?

A. Your contact details will be kept safely and securely and will only be used for this purpose and will not be shared with anyone else.

 

Q. How often will you contact me?

A. Not very often – perhaps about once every two or three months.

 

Q. What if I no longer wish to be on the contact list or I leave the surgery?

A. We will ask you to let us know by email if you do not wish to receive further messages.