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Signing Up For Patient Participation Group

Signing Up For Patient Participation Group
Title
Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979

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:

Your ethnic background

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

You attend the Practice

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.