Ellesmere Medical Centre Patient Representative Group

Would you like to have a say in how local health services are developed?

We are encouraging patients to give their views about how the practice is doing. We would like to be able to find out the opinions of as many patients as possible and are asking if people would like to provide their email addresses so we contact you by email every now and again to ask you a question or two.

If you are interested in being part of our Patient Representative Group, please click here to download a form or complete the online form below. Your contact details will only be used for this purpose and will be kept safely.

Thank you!

Name:
Address:
Email:

Please indicate if you would you prefer to be part of a group that meets in person, or by email:

In person
By email
No preference

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	Under 16		55 - 64 yrs
	17 - 24 yrs		65 - 74 yrs
	25 - 34 yrs		75 - 84 yrs
	35 - 44 yrs		Over 84
	45 - 54 yrs

To help us ensure our contact list is representative of our local community please indicate which of the following ethnic background you would most closely identify with.

White
British Group
Irish
Mixed
White & Black Caribbean
White & Black African
White & Asian
Asian or British
Indian
Pakistani
Bangladeshi
Black or Black British
Caribbean
African
Chinese or other Ethnic Group
Chinese
Any Other

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

Regularly
Occasionally
Very Rarely

 

 

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 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.

Common Q&A

Q Why are you asking people for their contact details?
A We would like to be able to contact people occasionally to ask questions about the surgery to identify areas for improvement.

Q Will my doctor see this information?
A This information is purely to contact patients to ask them questions about the surgery and ensure changes that are being made are patient focused. Your doctor might see general feedback from patients if they are responsible for making some of the changes in the surgery.

Q Will the questions you ask me be medical or personal?
A We will only ask general questions about the practice.

Q Who else will be able to access my contact details?
A Your contact details will be kept safely and securely and will only be used for this purpose and will not be shared with anyone else.

Q How often will you contact me?
A Two or three times a year.

Q What is a patient representative group?
A This is a group of volunteer patients who are involved in making sure the surgery provides the services its patients need.

Q What if I no longer wish to be on the contact list or I leave the surgery?
A If you do not wish to receive further messages, please send us an email to let us know.