Join our PPGWe welcome enquiries from patients who would like to join our patient group.Name*Email address* Post code*Additional informationThis 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 FemaleAge group*under 1617 - 2425 - 3435 - 4445 - 5455 - 6465 - 7475 - 84over 84EthnicityTo 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?*White: BritishWhite: IrishMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and AsianAsian Indian or British IndianAsian Pakistani or British PakistaniAsian Bangladeshi or British BangladeshiBlack Caribbean or British CaribbeanBlack African or British AfricanAny other Black backgroundChineseAny other ethnic groupHow would you describe how often you come to the practice?* Regularly Occasionally Very rarelyThank youBy submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.NameThis field is for validation purposes and should be left unchanged.
