Patient Participation Group Application Form

1
Name
First Name
Last Name
2
Email
example@example.com
3
Phone Number
Area Code
Phone Number
4
Why do you want to join the panel?
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Large
Normal
Small
Ok
Ok
5
Please describe any previous relevant experience
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Large
Normal
Small
Ok
Ok
6
Approximately how often do you come to the practice, on average?
1-2 times per year
3-4 times per year
5-11 times per year
Less than once a year
Monthly or more often
Should be Empty: