Patient Involvement Group Online Form

Patient Involvement Groups (also known as Patient Participation Groups) have a key role to play in the workings of a practice as they help ensure patients and their carers can influence their local services.

The role of the Patient Involvement Group includes:

being a critical friend to the practice
advising the practice on patient perspective, providing an insight into the quality of services
encouraging patients to take greater responsibility for their own health
researching the views of those who use the practice
participating in health promotion events
regularly communicating with the patient population.

If you would be prepared to help us with our Patient Involvement Group, please complete the information below.

Interest from people with experience and/or knowledge of any of the following would be most welcome:-

Disability
Mental health problems
Young people’s needs
Cancer and other incurable conditions
Carer duties.

The special needs of these patients can be overlooked in the system and additional focus within the Patient Involvement Group could provide useful suggestions for improvements.

Title *

Name *

Surname *

Date of Birth *

Email *

Phone

Postcode *

Further Details

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

Gender *

Male

Female

Other

Your Age *

The ethnic background with which you most closely identify is: *

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

Regularly

Occasionally

Very Rarely

Final Questions

Just so we can learn a little more about you, we would be grateful if you could answer the following questions:

1. How did you hear about the Patient Involvement Group?

2. Why do you want to join the Patient Involvement Group?

3. What qualities would you offer to the Patient Involvement Group?

Your submission will be forwarded to the Patient Involvement Group chairperson who will then make appropriate contact.