Payments – Card or cheque only. « Cricketfield Surgery

Name*

First Last

Email

Our preferred method of contact is via email so please supply one if you have one. If you do not have an email then hard copies of minutes etc will be sent out.

Main Contact Number

Alternative Contact Number

Address

Are you on Social Media?

Facebook
Twitter
Instagram
None

Please select any that are relevant.

Employment Status*

Employed Full Time
Employed Part Time
Full Time Student
Stay at Home Parent/Carer
Retired
Self Emplpyed
Other

If other -

Preferred Meeting Time*

AM - Before 12pm
Second ChoicePM - After 12pm
Evening - After 5pm
Any Time
Other - please specify below

If "Other" please specify -

Specific areas of interest*

Mental Health
Chronic Illnesses
Patient Care
Community Links
Wider NHS View
Other (Please specify below)

If "Other" please specify -

Potential Areas for Contribution*

eg - Fundraising, Event Planning, Volunteer Coordination etc.

Do you have any queries about joining the PPG?*

Thank you for your interest in Cricketfield Patient Participation Group. We will be in touch soon, although please note that forms may take a few weeks to process. Any questions in the mean time please email cricketfieldppg@gmail.com. Thank you.

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