Signing Up For Our Patient Participation Group

If you are happy for us to contact you periodically by email, please complete the form below.

Name:

Email Address:

Telephone:

Postcode:

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:

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

Thank you

Please note that we will not respond to any medical information or questions received through the form.

The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Grove Surgery • 200–202 Chadwell Heath Lane, Chadwell Heath, Romford , Essex , RM6 4YU.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Signing Up For Our Patient Participation Group

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