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Wembley Park Medical Centre
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Signing Up For Patient Participation Group
Signing Up For Patient Participation Group
Title
Mr
Mrs
Miss
Miss
Other
Other
First Name
Last Name
Email
Enter Email
Confirm Email
Confirm Email
Date of birth
Please use format day/month/year e.g. 12/05/1979
Phone Number
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
Male
Female
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:
Your ethnic background
White British
White Irish
Mixed White & Black Caribbean
Mixed White & Black African
Mixed White & Asian
Indian – Asian or Asian British
Pakistani – Asian or Asian British
Bangladeshi – Asian or Asian British
Caribbean – Black or Black British
African – Black or Black British
Chinese
Any other
How would you describe how often you come to the Practice?
You attend the Practice
Regularly
Occasionally
Very Rarely
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.
I consent to the Practice collecting and storing my data from this form.
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