Stethoscope

Stack Garth | Brandon | Durham | DH7 8SJ | telephone 0191 378 2099

Brandon Lane Surgery

 

 

 

 

Electronic Submissions

The practice wishes to expand on our current Patient Participation “Virtual Group” in order to consult with patients from time to time. This is in addition to the Practice Patient Participation Group. If you are happy for us to contact you via e-mail please complete this form. The information you supply will help to make sure we try to consult with a representative sample of patients registered at our practice and ensure our “Virtual Group” is representative of our local community.


Your Details
Title MrMrsMissMs
First Name
Last Name
Email Address
Telephone
Street Address
Town
Postcode

Your Gender MaleFemale

Your Age

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

How often do you visit the Practice? RegularlyOccasionallyRarely
Employment
EmployedUnemployedRetiredSchool StudentStudent/Durham University
Health
Are you a Carer? YESNO
Are you responsible for anyone with learning disabilities? YESNO
Please indicate your health priorities:

Data Protection Act

The practice wishes to expand on our current Patient Participation “Virtual Group” in order to consult with patients from time to time. This is in addition to the Practice Patient Participation Group. If you are happy for us to contact you via e-mail please complete this form. The information you supply will help to make sure we try to consult with a representative sample of patients registered at our practice and ensure our “Virtual Group” is representative of our local community.


Your Details
Title MrMrsMissMs
First Name
Last Name
Email Address
Telephone
Street Address
Town
Postcode

Your Gender MaleFemale

Your Age

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

How often do you visit the Practice? RegularlyOccasionallyRarely
Employment
EmployedUnemployedRetiredSchool StudentStudent/Durham University
Health
Are you a Carer? YESNO
Are you responsible for anyone with learning disabilities? YESNO
Please indicate your health priorities:

Virtual Patient Participation Group Sign-Up

The practice wishes to expand on our current Patient Participation “Virtual Group” in order to consult with patients from time to time. This is in addition to the Practice Patient Participation Group. If you are happy for us to contact you via e-mail please complete this form. The information you supply will help to make sure we try to consult with a representative sample of patients registered at our practice and ensure our “Virtual Group” is representative of our local community.


Your Details
Title MrMrsMissMs
First Name
Last Name
Email Address
Telephone
Street Address
Town
Postcode

Your Gender MaleFemale

Your Age

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

How often do you visit the Practice? RegularlyOccasionallyRarely
Employment
EmployedUnemployedRetiredSchool StudentStudent/Durham University
Health
Are you a Carer? YESNO
Are you responsible for anyone with learning disabilities? YESNO
Please indicate your health priorities: