Join our Patient Reference Group We would like to know how we can improve our services to you and we would welcome your thoughts about our surgery and staff. If you are happy for us to contact you occasionally by email or post please complete the form. Join our Patient Reference Group Patient participation group recruitment form 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?*MaleFemaleAge 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?*RegularlyOccasionallyVery rarelyThank youPlease note that no medical information or questions will be responded to. 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.NameThis field is for validation purposes and should be left unchanged.