Back Sign Up For Patient Reference Group If you are happy for us to contact you periodically by email please complete the form here. Signup for Patient Participation Group First Name * Last Name * Email * Enter Email Confirm Email * Confirm Email Date of birth * Please use format day/month/year e.g. 12/05/1979 Postcode Phone Number * Personal Details 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 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 White Irish White & Black Caribbean White & Asian White & Black African Indian Bangladeshi Pakistani Caribbean African Chinese Any Other How would you describe how often you come to the practice? Regularly Occasionally Very Rarely Privacy Policy This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. * I consent to the practice collecting and storing my data from this form. reCAPTCHA If you are human, leave this field blank. Send