Patient Reference Group Sign-Up PPG Sign Up Title * Mr Mrs Miss Ms Other Name * Surname * Email * Telephone Number * Postcode * The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice. Gender * Male Female Other 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: * How would you describe how often you come to the practice? Regularly Occasionally Very Rarely 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. If you are human, leave this field blank. Submit Non-urgent advice: Please NoteWe will not respond to any medical information or questions received via this form.