We’re looking for patients and carers to get involved in The Potteries Surgery Patient Participation Group (PPG).

The PPG gives patients an opportunity to share feedback, discuss ideas and help us improve services and the experience of our patients.

If you’re interested in getting involved, please complete this short form. We’ll use the details you provide to contact you about the PPG and future opportunities to take part.

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1. What is your full name?

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2. What is your email address?

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3. What is your telephone number?

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4. Are you:

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5. Why are you interested in joining the Patient Participation Group?

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6. Is there anything in particular you’d be interested in discussing or contributing to through the PPG?

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7. Are you happy for The Potteries Surgery to contact you about the PPG using the details you’ve provided?

Thank you for your interest

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