Eden Surgery, Cavendish Road, Ilkeston, Derbyshire, DE7 5AN.  Tel: 0115 9444081

Expression of Interest for our Patient Participation Group.





The information below will help to make sure we receive feedback from a representative sample of the patients registered at Aitune.

MaleFemale

Under 1617-2425-3435-4445-5455-6465-7475 +

The ethnic background you most closely identify with is:

British groupIrish

White and Black CaribbeanWhite and AsianWhite and Black African

IndianBangladeshiPakistani

CaribbeanAfrican

ChineseAny other

RegularlyOccasionallyRarely

Thank you for expressing your interest to join our Patient Participation Group.

Please note, no medical queries or information received via this form will be responded to.

The information you provide us with will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure this information is handled correctly.