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 GDPR Regulations. GDPR 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:

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 Bangladeshi Indian Pakistani
Black or Black British Caribbean African
Chinese or Other Chinese Any Other
How would you describe how often you come to the practice?
Please choose an option Regularly Occasionally Very Rarely

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 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 Over 84