Join our PPG – Kirby Road Surgery

We are now recruiting patients for our PPG!

Please fill out the form below or email admin.kirbyroad@nhs.net to register your interest!

We aim to reply within 2 working days

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
Consent*
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.
Thank you
Name
This field is for validation purposes and should be left unchanged.

Additional information