Join Patient Participation Group

If you would like to become a member of the Patient Group, please complete our online form below.

Your Details

Your name

Date of BirthPlease provide in the format dd/mm/yyyy, for example 18/01/1970

Are you able to provide your NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

E-mail Address

Postcode

Gender

Which of the following ethnic backgrounds do you most closely identify with?

How would you describe how often you come to the practice?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Southend Road Surgery • 114 Giffords Cross Road, Corringham, Stanford-Le-Hope, Essex, SS17 7QQ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.