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PPG Form

Patient Details - Please complete the text boxes and tick where appropriate.  All questions marked with an asterisk * are compulsory.

Signing Up For Patient Reference Group

If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.


*First Name 


*Email Address

*Phone Number 


*Date of Birth 

The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.

Your Gender 

Your Age

The ethnic background with which you most closely identify is:



Asian or Asian British 

Black or Black British

Chinese or Other

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

Please choose an option


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Stockbridge Village Medical Centre
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