My details are as follows:

                Name: ………………………………………………………………………………

                DOB: ………………………………………………………………………………….

                Email: ………………………………………………………………………………..

       Address: ……………………………………………………………………………

(Only required if not on email)

I would like to join the PPG on the following basis – please tick one:

I would like to become a member of the Market Cross Surgery PPG and would be willing to attend quarterly meetings at the surgery.

I would prefer not to attend any face to face meetings but I would like to become a member of the ‘virtual’ PPG group.

I consent to the practice contacting me on Patient Participation Group issues (including by email if I have provided my email address above)

                Signed: …………………………………………………….

                Dated: ……………………………………………………..