Join our PPG

We welcome enquiries from patients who would like to join our patient group.

Download and complete the form below, or complete and submit our online form.

For more information contact Amal Shantir on 020 8520 7115

Patient participation group recruitment form

Name*
Email address*
Post code*
Additional information
This additional information will help to make sure we try to speak to a representative sample of the patients that are registered at this practice.
Are you?*
- Male
- Female
Age group*
Ethnicity
To help us ensure our contact list is representative of our local community please indicate which of the following ethnic backgrounds you would most closely identify with?
What is your ethnicity?*
How would you describe how often you come to the practice?*
- Regularly
- Occasionally
- Very rarely
Thank you
Please note that no medical information or questions will be responded to. The information you supply us will be used lawfully, in accordance with the Data Protection Act 2018. The Data Protection Act 2018 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.
Name
This field is for validation purposes and should be left unchanged.

Additional information