PPG registration form

Thank you for your interest in joining our PPG. Please complete the registration form below and we will be in touch.

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Which surgery are you registered with? *

• Miriam Medical Centre
• Earlston & Seabank Medical Centre

Your name *

First

Last

Your email address *

Your telephone number *

Your postcode *

What is your sex? *

• Male
• Female

Which age group are you in? *Please select age group…Under 1617 to 2425 to 3435 to 4445 to 5455 to 6465 to 7475 to 8485 and over

What is your ethnicity?Please select ethnicity…White – BritishWhite – IrishWhite – Any other White backgroundMixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed – Any other mixed backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian or Asian British – Any other Asian backgroundBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – Any other Black backgroundOther Ethnic Groups – ChineseOther Ethnic Groups – Any other ethnic groupNot stated

How often do you attend the surgery? *

• Regularly
• Occasionally
• Rarely

Submit PPG registration