Join Patient Reference Group

St Mary's Surgery is in the process of establishing a Patient Reference Group (PRG) to gain the views of our registered patients and ensure they are involved in decisions about the range and quality of the services provided by our practice.

If you are interested in becoming a PRG member, please submit your details using the form below. Providing this information will help us to ensure that the PRG is as representative as possible of our practice population as a whole. The information you supply will be used lawfully, in accordance with the UK General Data Protection Regulation (UK GDPR).

Your Details

Your name

Date of BirthPlease provide in the format dd/mm/yyyy, for example 18/01/1970

Are you able to provide your NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

E-mail Address

Postcode

Gender

Which of the following ethnic backgrounds do you most closely identify with?

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

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 St Mary's Surgery • Pinfold Health Centre, Field Road, Bloxwich, WS3 3JP.

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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