Signing up for our Patient Participation Group
 
If you are happy for us to contact you periodically by email please leave your details below and hand this form in at reception.

Name:                      ……………………………………………………………………
Email Address:        ……………………………………………………………………
Telephone:               …………………………………………………………………..
Postcode:                 …………………………………………………………………..

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

Your Gender:           Man □      Woman □    Transgender  □       
                           Non-binary/non-conforming  □        Prefer not to respond  □

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 □        Irish □      Other White background  □   
Mixed                                White &Asian  □   White & Black African  □    White and Black Caribbean  □    
                                            White & Black Caribbean  □      Other mixed background  □
Asian or Asian British     Bangladeshi  □         Indian  □          Pakistani  □       Other Asian background  □
Black or Black British     African  □      Caribbean  □         Other Black background  □
Chinese or other           Chinese  □       Prefer not to disclose my ethnicity  □      

How would you describe how often you come to the practice?
Regularly  □           Occasionally  □          Rarely  □        Very rarely  □         

Thank you
Please note that we will not respond to any medical information or questions received through this questionnaire.

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 info is held about you, and sets out rules to make sure that this is handled properly.