Patient Participation Group
Expression of Interest

If you are happy for us to contact you periodically please complete the following form:

Name:
Date of Birth:
Email address:
Contact Tel:
Address:
Postcode:

Are you?

Male

Female

Age Group:

Under 16		55 - 64 yrs
17 - 24 yrs		65 - 74 yrs
25 - 34 yrs		75 - 84 yrs
35 - 44 yrs		Over 84
45 - 54 yrs

To help us ensure our contact list is representative of our local community please indicate which of the following ethnic background you would most closely identify with?

White
British Group
Irish
Mixed
White & Black Caribbean
White & Black African
White & Asian
Asian or British
Indian
Pakistani
Bangladeshi
Black or Black British
Caribbean
African
Chinese or other Ethnic Group
Chinese
Any Other

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

Regularly
Occasionally
Very rarely

Please 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.