FARNHAM MEDICAL CENTRE

Dr C S Sandbach						435 Stanhope Road
Dr M Evans							South Shields
Dr F R Brettell						Tyne and Wear
Dr D Power							NE33 4QY
Dr M J Orr							Tel 0191 4554748	
Dr R J Curtis							Secretary 0191 4562066
Dr R A Gill							Fax No 0191 4558573

CONTACT FORM

If you are happy for us to contact you periodically by e-mail please leave your details below and hand this form back to reception, via post or e-mail.

Name:
E-mail address:
Postcode:

This additional information will help to make sure we try to speak to a representative sample of the patients registered at this practice.

Are you?		Male  			Female	    
Age Group	Under 18		55-64		
	18-24		65-74		
	25-34		75-84		
	35-44		85 and over		
	45-54		
To help us ensure our contact list is a representative of our local community please indicate which of the following ethnic background you would most closely identify with?
White						
British Group		Irish				
Mixed						
White & Black Caribbean		White & Black African		White & Asian		
Asian or Asian British						
Indian		Pakistani		Bangladeshi		
Black or Black British						
Caribbean		African				
Chinese or other ethnic Group 						
Chinese		Any other				

How would you describe how often you come to the practice?
Regularly		Occasionally		Rarely	
Thank you
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 this information is handled properly.
Common patient question and answers

Q	Why are you asking people for their contact details?
A	We would like to be able to contact people occasionally to ask them questions about the surgery and how well we are doing to identify areas for improvement.

Q	Will my doctor see this information?
A	This information is purely to contact patients to ask them questions about the surgery, how well we are doing and ensure changes that are being made are patient focused.  If your doctor is responsible for making some of the changes in the surgery they might see general feedback from patients.

Q	Will the questions you ask be medical or personal?
A	We will only ask general questions about the practice, such as short questionnaires.

Q	Who else will be able to access my contact details?
A	Your contact details will be kept safely and securely and will only be used for this purpose and will not be shared with anyone else.

Q	How often will you contact me?
A	Not very often.

Q	What is a patient group/patient participation group?
A	This is a group of volunteer patients who are involved in making sure the surgery provides the services its patients need.

Q	Do I have to leave my contact details?
A	No but if you change your mind, please let us know.

Q	What if I no longer wish to be on the contact list or I leave the surgery?
A	We will ask you to let us know by e-mail if you do not wish to receive further messages.