Sign Up for the Patient Participation Group

Signing Up For Patient Participation Group

Please complete this brief form to join the Holborn Medical Centre Patient Participation Group (PPG).

We prefer to use text messaging to communicate regarding the PPG, as emails often get filtered as spam. Please confirm you are happy for us to contact you by text/sms.

First Name

Last Name

Date of birth

Please use format day/month/year e.g. 12/05/1979

Mobile Phone Number

Consent to be contacted via Text Message/SMS

I consent to being contacted by Text Message

I do NOT consent to being contacted by Text Message/SMS

I would prefer to be contacted via…

Preferred phone number

Email address

Consent to contact via email

I consent to being contacted by email

Please be aware that emails from the Practice may be filtered to your Spam/Junk folder.

If you are human, leave this field blank.