This survey is now closed
Signing Up For Our Patient Reference 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.
This survey is now closed