PPG Sign Up Form Title Mr Mrs Miss Ms Mx Dr Other First NamesSurnameEmail Enter Email Optional Confirm Email Optional Contact NumberDate of Birth Day Month Year The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.Your Age Under 16 17-24 25-34 35-44 45-54 55-64 65-74 75-84 Over 84 How would you describe how often you come to the practice? Regularly Occasionally Very Rarely Please choose your Preferred Surgery OptionalPlease choose an optionSpark Medical Group – The Brook SurgerySpark Medical Group – St GeorgesPlease choose your meeting preference OptionalPlease choose an optionFace-to-Face (at the surgery)Online via Microsoft TeamsWhy would you like to join the PPG? OptionalTo help us build a diverse and representative group, please tell us a little about yourselfAny particular areas of interest? OptionalE.g Long-term conditions, young people, carers, digital servicesConsent Please tick here to confirm Optional By completing this form, I confirm I am a patient registered with Spark Medical Group and agree to be contacted about the PPG.