Signing Up For Patient Participation Group

Email *

The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this Practice.

Your Gender *MaleFemaleOther

Your age *Under 1617–2425–3435–4445–5455–6465–7475–84Over 84

The ethnic background with which you most closely identify is *White BritishWhite IrishMixed White & Black CaribbeanMixed White & Black AfricanMixed White & AsianIndian – Asian or Asian BritishPakistani – Asian or Asian BritishBangladeshi – Asian or Asian BritishCaribbean – Black or Black BritishAfrican – Black or Black BritishChineseAny other

How would you describe how often you come to the Practice? *RegularlyOccasionallyVery Rarely

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *I consent to the Practice collecting and storing my data from this form.