Patient Participation Group (PPG) – Application

Online Form to join the PPG

Application to join The lakes Medical Practice Virtual PPG and agree to the terms of the group.

Are you registered as a patient at The Lakes Medical Practice? *

Yes

First Name: *

Surname: *

Postcode *

Please enter your E-mail address to be used in order to contact you in relation to the Patient Participation Group. IMPORTANT - By providing your e-mail address you are agreeing that this can be passed to the current PPG Chair

Please enter a mobile number in order for us to send patient participation group text messages

You may choose to be either a friend of the committee, or apply for a position on the committee, please indicate Group or Committee Member preference. Full committee members attend PPG meetings monthly or bi-monthly and may hold the volunatry post of Chair, Co-Chair, Vice Chair or Secretary. Friends of the committee help and support the Core Committee with health awareness days, fundraising, publicising and sharing information. Members will follow the same Code of Conduct as those in the Core Committee. *

Agreement: Do you agree to the rules of the group, ALL boxes must be ticked by way of agreement: *

No sharing of medical information or requests for medical advice

No offensive or abusive language - Agree to be kind and courteous and respect the views of others

The PPG is not a complaints forum. No raising individual complaints

Respect the groups and practice privacy/confidentiality at all times

I have read and understand all practice privacy and data protection policies available at www.thelakesmedicalpractice.co.uk

Information submitted through secure forms is used only for the purposes of processing your request and retained for the entirity of your involvement on the Patient Participation Group as a record of joining and agreement to terms. We may be in touch with you in relation to the information submitted. All Information submitted through secure forms is accessed over a secure connection by nominated staff and then held on a password protected file on the practice intranet. We have a strict confidentiality policy. This information is not shared with any external third party organisations other than the chair and committee members of the Patient Participation Group who are practice volunteers. Information is retained in online format for up to 28 days before being transfered to the practice intranet system by way of record keeping for active PPG members.

Checkboxes *

I consent to my information being used for the purposes described aboveand wish to submit this online form to The Lakes Medical Practice, Bridge Lane, Penrith CA11 8HW