Violet Lane Medical Practice

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PPG Signup Form

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All questions marked with a * are mandatory

Patient Participation Group Sign Up

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May be used to identify you

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As the PPG acts independantly to that of the surgery, we will need to pass on your contact details to enable them to get in touch

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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