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Signing Up For Our Virtual 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:

 

………………………………………………………………….


Postcode:

 

………………………………………………………………….

 

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

25 – 34

45 – 54

65 – 74

 

17 – 24

35 – 44

55 – 64

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

 

 

Thank you

 

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.

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