Join our PPG We welcome enquiries from patients who would like to join our patient group. Name * First Name Last Name Email * example@example.com Post Code * Additional information This additional information will help to make sure we try to speak to a representative sample of the patients that are registered at this practice. Are you * Male Female Age Group * Please Select Under 16 17 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 Over 84 Ethnicity To help us ensure our contact list is representative of our local community please indicate which of the following ethnic backgrounds you would most closely identify with? What is your ethnicity? * Please Select White: British White: Irish Mixed: White and Black Caribbean Mixed: White and Black African Mixed: White and Asain Asian Indian or British Indian Asian Pakistani or British Pakistani Asian Bangladeshi or British Bangladeshi Black Caribbean or British Caribbean Black African or British African Any other background Chinese Any other ethnic group How would you describe how often you come to the practice? Regularly Occasionally Very rarely Thank you Please note that no medical information or questions will be responded to. 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. Submit Should be Empty:
