St Leonards Practice Virtual Patient Group
Join our patient group

If you are happy for us to contact you periodically by email please fill out this form.

If you would prefer to sign up for our group without using this online form, please go here to download a printable form which you can hand in to reception.

The information you supply here will help to make sure we try to speak to a representative sample of the patients that are registered at this practice and ensure our group is representative of our local community.

Please complete all fields

First name
Second name
Email address
Sex   Postcode
Your date of birth dd   mm   yyyy
With which ethnic background would you most closely identify?
How often you come to the practice?  


About This Form

The information you supply us 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 that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.