Virtual Patient Group

HILLVIEW MEDICAL CENTRE Woking, surrey Tel 01483 760707

	Virtual Patient Group	*Contact Us* Accessibility Disclaimer

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AUTUMN 2011
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Join Our Email Group

Help us to improve our services by joining our virtual patient participation group.

If you are happy for us to contact you periodically by email please complete your details and return this form to a member of staff or post it in the secure box on the main reception desk.

Name:
Email address:
Postcode:
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:*
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?* Regularly Occasionally Very rarely
Note: This will clear the entire form.

Thank you for completing your contact form we will be in contact soon.

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.