PPG Application

Thank you very much for your participation.

Please note that no medical information or questions will be responded to.
Everyone working for the NHS has a legal duty to keep information about you confidential.

We understand how important it is to keep your personal information safe and secure and we take this very seriously. We have taken steps to make sure your personal information is looked after in the best possible way and we review this regularly.

Please read our privacy notice (‘Privacy Notice’) carefully, as it contains important information about how we use the personal and healthcare information we collect on your behalf.

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* 1. Are you a patient of Dr Agarwal's Practice?

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* 2. Address

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* 3. Are you male or female?

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* 4. Your age group:

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* 5. Are you a carer?

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* 6. Which race/ethnicity best describes you? (Please choose only one.)

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* 7. How would you describe how often you come to the practice?

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