PPG Membership and Contact Form

Please complete this form if you are happy for the Patient Participation Group (PPG) to contact you from time to time or if you would like to become a member of the PPG. By giving your contact details below, you are agreeing to the UMP’s Privacy Policy. Completion of this form will be taken as consent for the PPG to contact you using the information on this form.

Details

Title *

Full name *

Email Address *

Postal Address *

Postcode *

Mobile Phone Number

Home Phone Number

Are you happy to be contacted from the PPG or would you like to become a member? *

Become a member

Contact only

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Page last reviewed: 16 November 2020
Page created: 10 November 2026

Cookies on the University Medical Practice website

PPG Membership and Contact Form

Further Information