Patient Reference Group Application Form
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2. Please tell us which GP practice you are registered with.
| Please select your practice |
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| List of GP practices in Enfield | |
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3. Please enter the first part of your postcode e.g. EN1, N13 *
4. Please tell us your email address
5. Please confirm any alternative contact details (e.g. address and/or telephone number)
6. Please tell us the NHS local services that you have experience in using as a patient/carer. Please use this space to tell us the name of the services.
7. Please tell us in under 500 words, why you are interested in being a member of the Patient Reference Group. We are looking for patients with experience of local NHS services. You are welcome to tell us of any other voluntary roles or experience you have, but as this role is about representing patients and carers as individual service users, we also welcome applications from people who have never volunteered before.
8. Please tell us if you would need any extra support to participate in the patient reference group and what kind of help you would need.