Red Kite photograph.  With kind permission from Gerry Whitlow.

 
Chequers Drive
and Hughenden Valley Surgeries
 Patient Group


Would you like to have a say about the services provided at our practice?

Dr Mitchell & Partners would like to hear your views and are setting up a Patient Reference Group. To allow the broadest coverage and reduce complexity this will be primarily run as a virtual group; exchanging views and ideas via email communication with face-to-face meeting only once or twice a year.

By providing your email details we can add them to a contact list that will mean we can get in touch with you every now and again to ask you a question or two relating to the surgery and local care. You will also have an opportunity to exchange views with all group members and make suggestions, giving you the chance to help shape your services.

Initially we are collating interested participants from our registered patients. Please submit the following details.

please read this notice: This form is not sent via a secure server and is just like sending a normal email. Complete confidentiality can not be guaranteed.

Patients Name*
Email Address*
Postcode
* You must provide this information.

This additional information will help to make sure we try to speak to a representative sample of the patients that are registered at The Elms.
Please tick appropriate boxes:
 
Are you? Male Female  
       
Age group      
Under 16 17-24
25-34 35-44
45-54 55-64
65-74 75-84
Over 84    
       
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?
 
How would you describe how often you come to the practice?
 
 
Please note that no medical requests 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 handed properly.

   


 

© Chequers Drive and Hughenden Valley Surgeries  2006-12    Red kite photograph with kind permission from photographer Gerry Whitlow - www.hyelms.com     Website design Internet-GP