Beauchamp House Surgery: Patient Participation Group
Membership Enquiry Form
Which group are you interested in joining?
The core Patient Participation Group (PPG)
This Group meets practice staff to discuss current issues and proposals. Meetings
are usually every other month in the evenings at the surgery. If you tick this box,
then when numbers allow, the PPG will invite you to attend a meeting so you can
decide whether to join.
The wider Patient Consultative Group (PCG)
These patients do not meet, but the PPG may ask them for views on specific issues
as needed. These patients do not see each other’s contact details.
Eligibility:
Please can you confirm:
I am at least 16 years old, and have been registered as a Beauchamp House
Surgery patient for at least six months.
Please tell us how to contact you:
Name:
Email (or full postal address if you
are not contactable by email):
By submitting this form, you are consenting to Beauchamp House Surgery and the
Beauchamp House Patient Participation Group contacting you as above.
If you are willing to provide it, the information below will help us to measure how well the
groups represent patients at the Practice. Thank you.
Age Group:
Gender:
16 - 24
55 - 64
Male
25 - 34
65 - 74
Female
35 - 44
75 - 84
45 - 54
Over 84
How often do you currently come to the surgery?
Frequently (4 or
Occasionally (1 more times a year)
3 times a year)
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Post code:
Rarely (less than
once a year)
What is your ethnic group?
Please choose one option that best describes your ethnic group or background:
White
Black / African / Caribbean / Black British
English / Welsh / Scottish / Northern
Irish / British
African
Irish
Caribbean
Gypsy or Irish Traveller
Any other Black / African / Caribbean
background
Any other White background
Mixed / Multiple ethnic groups
Asian / Asian British
White and Black Caribbean
Indian
White and Black African
Pakistani
White and Asian
Bangladeshi
Any other Mixed / Multiple ethnic
background
Chinese
Any other Asian background
Other ethnic group
Arab
Any other ethnic group
Please do not include any medical information or medical questions: they should be
referred to the Practice instead.
When complete, please submit to the Patient Participation Group
 by hand at the Surgery or
 by post to
PPG membership, c/o Beauchamp House Surgery,
37 Baddow Road, Chelmsford, CM2 0DB.
The information you supply 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.
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