• Homepage
• How do I ...?
• Services & Clinics
• Online Services
• The Team
• Patient Groups

Patient Reference Group Sign-up

in association with Merritt Medical Centre Patient Participation Group

---

Thank you for agreeing to take part in Hook Surgery's Patient Reference Group. In collaboration with the Patient Participation Group, we will occasionally send out a survey to the email address you provide (or postal address if you do not have email) with questions about the care and services we provide. Your answers will help us to know how well we are meeting your needs and what we can do to improve.

We ask for your name and address both to know where to send the surveys and to confirm that you are a patient with us. The data from the surveys will be anonymised and will not be linked to your name. We are asking further questions such as your age and ethnicity in order to ensure we have a representative sample of responses.

Name :       Email address :       Home address :       Sex : Male Female       Age : under 17 17-24 25-44 45-64 65-74 75-84 85 or over         Ethnicity : White British White Irish Other White Mixed White and Black Caribbean Mixed White and Black African Mixed White and Asian Other Mixed Indian Pakistani Bangladeshi Sri Lankan Korean Black Caribbean Black African Other Black Chinese Other Ethnic Group       How often do you visit the surgery? : more than 4 times a year 2-4 times a year once a year or less       If you do not want to be contacted by the Patient Participation Group about surgery events, please tick this box.

---

© Hook Surgery 2011