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Call Us: 01795 580402 (Om Medical Centre)
01795 876016 (Shiva Medical Centre)
Om Medical Centre: 08:00 - 20:00 Monday | 08:00 - 18:30 Tuesday to Friday
Shiva Medical Centre: Mon. 08:30 - 17:00 | Tues. 08:30 - 17:00 | Wed. 08:30 -14:00 | Thur. 08:30 - 17:00 | Fri. 08:30 - 14:00
CQC Rating
GOOD
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Signing up for Patient Participation Group
Please fill in the form to be considered for inclusion in our patient participation group
Title
Mr
Mrs
Miss
Other
First Name
Last Name
Email
Confirm Email
Date of Birth
Phone Number
Gender
Male
Female
The ethnic background with which you most closely indentify is:
White British
White Irish
Mixed White & Black Caribbean
Mixed White & Black African
Mixed White & Asian
Indian – Asian or Asian British
Pakistani – Asian or Asian British
Bangladeshi – Asian or Asian British
Caribbean – Black or Black British
African – Black or Black British
Chinese
Any other
How often do you attend the practice?
Regularly
Occasionally
Very Rarely
Consent
Privacy Policy This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
Let us know why you would like to be involved in our PPG
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