About This Form

Fields marked with a 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.

    Signing Up For Patient Reference Group

    Your Details - If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.

    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

    Your Age

    The ethnic background with which you most closely identify is:

    White:

    Mixed:

    Asian or Asian British:

    Black or Black British:

    Other ethnic group:

    How would you describe how often you come to the practice?

    Please choose an option