Signing Up For Patient Reference Group

About This Form

Fields marked with a red asterisk are
compulsory.

Please note that we will not respond to any medical information or questions received through the survey.

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 that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Title	Mr Mrs Miss Ms
First Name(s)
Surname
Email Address
Telephone
Postcode		Date of Birth
Usual Surgery:

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	Male	Female

Your Age	Under 16	17 - 24
	25 - 34	35 - 44
	45 - 54	55 - 64
	65 - 74	75 - 84
		Over 84

The ethnic background with which you most closely identify is:
White	British Group	Irish
Mixed	White & Black Caribbean White & Asian	White & Black African
Asian or Asian British	Indian Bangladeshi	Pakistani
Black or Black British	Caribbean	African
Chinese or Other	Chinese	Any Other
How would you describe how often you come to the practice?
Regularly	Occasionally	Very Rarely