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Felmores Medical Centre

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Friends and Family Survey
Changes To Your Inhaler
How Can We Help?
New Patients
Appointments
Prescriptions
Sick Notes
Health Advice
Practice Services

Opening Hours
Contact Us
Our Team
Patient Record
Practice News

PPG Sign Up Form

Please use this form if you would like to join our Patient Participation Group

Last Updated: 13/10/2021

Your Details

Name *

Date of Birth *

Phone *

E-mail

Representation

Gender

Male

Female

Other

Age

Under 16

17 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75 - 84

Over 85

Ethnicity

White British

White Irish

White Other

Black British

Black African

Black Caribbean

Black Other

Asian Chinese

Asian Indian

Asian Pakistani

Asian Other

White + Black British

White + Black African

White + Black Caribbean

White + Chinese

White + Indian

White + Pakistani

Other

Attendance

How often do you attend the practice?

Regularly

Occasionally

Very Rarely

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