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About Us
At the Practice
Baby Friendly
Chaperones
Non-Smoking Premises
Have your say
Complaints
Friends and Family Test
Compliments and Suggestions
Patient Opinion
Patient Participation Group
Patient Survey
Our Team
Doctors
Nurses
Allied Health Professionals
Practice Team
Practice Policies
Accessible Information Standard
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Patient Record
Accessing your Record
Access for Others
Subject Access Requests(SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Organ Donation
Sharing your Information with Others
Summary Care Records (SCR)
How we use your Data
Confidentiality
Online Access
Proxy Access
Privacy Policy
Quality Assurance
Removal of Patients from our List
Rights and Responsibilities
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Safeguarding Children
Shared Decision Making
Social Media
Unacceptable Actions Policy
Website
Accessibility
Copyright
Cookie Policy
Disclaimer
Your Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Zero Tolerance
Regulations & Governance
CQC
CCG
GP earnings
NHS services
The NHS Constitution for England
Teenage Friendly
Can I see the GP or Nurse on my own?
Job Vacancies
Contact
How to Contact Us
Opening Hours
Location
Send a Message
Other Local Services
Clinics & Services
Appointments, Tests & Referrals
General Appointments
Referrals
Cancel an Appointment
Get Medical Advice
Evening and Weekend appointments
Help with your GP Appointment
How to use the online consultation form, see a doctor or healthcare professional, test and investigations
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
See a Doctor or Healthcare Professional
Tests & Investigations
Getting Test Results
Urine Tests
X-Rays & Scans
What is a Blood Test?
Common Tests
Clinics
Antenatal Care
Child Health Checks
Chiropody
Long Term Conditions
NHS Health Check aged 40 – 74
Travel & Holiday Vaccinations
Online Services
NHS App
Register for Online Services
Practice Services
Advocacy Service
Electronic Prescriptions
Hepatitis B Immunisation
Home Visits
Interpreting Service
NHS screening
Order a Repeat Prescription
Private Services
Patient Transport Service
Register as a New Patient
Further Help about how to Register with a GP
Registration Policy
Temporary Services
Sick/Fit Note
Vaccinations
Wasted Medications
Your Record
Update Your Details
Help & Support
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Signing Up For Patient Participation Group
Signing Up For Patient Participation Group
Title
*
First Name
Last Name
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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Home
About Us
At the Practice
Baby Friendly
Chaperones
Non-Smoking Premises
Have your say
Complaints
Friends and Family Test
Compliments and Suggestions
Patient Opinion
Patient Participation Group
Patient Survey
Our Team
Doctors
Nurses
Allied Health Professionals
Practice Team
Practice Policies
Accessible Information Standard
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Patient Record
Accessing your Record
Access for Others
Subject Access Requests(SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Organ Donation
Sharing your Information with Others
Summary Care Records (SCR)
How we use your Data
Confidentiality
Online Access
Proxy Access
Privacy Policy
Quality Assurance
Removal of Patients from our List
Rights and Responsibilities
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Safeguarding Children
Shared Decision Making
Social Media
Unacceptable Actions Policy
Website
Accessibility
Copyright
Cookie Policy
Disclaimer
Your Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Zero Tolerance
Regulations & Governance
CQC
CCG
GP earnings
NHS services
The NHS Constitution for England
Teenage Friendly
Can I see the GP or Nurse on my own?
Job Vacancies
Contact
How to Contact Us
Opening Hours
Location
Send a Message
Other Local Services
Clinics & Services
Appointments, Tests & Referrals
General Appointments
Referrals
Cancel an Appointment
Get Medical Advice
Evening and Weekend appointments
Help with your GP Appointment
How to use the online consultation form, see a doctor or healthcare professional, test and investigations
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
See a Doctor or Healthcare Professional
Tests & Investigations
Getting Test Results
Urine Tests
X-Rays & Scans
What is a Blood Test?
Common Tests
Clinics
Antenatal Care
Child Health Checks
Chiropody
Long Term Conditions
NHS Health Check aged 40 – 74
Travel & Holiday Vaccinations
Online Services
NHS App
Register for Online Services
Practice Services
Advocacy Service
Electronic Prescriptions
Hepatitis B Immunisation
Home Visits
Interpreting Service
NHS screening
Order a Repeat Prescription
Private Services
Patient Transport Service
Register as a New Patient
Further Help about how to Register with a GP
Registration Policy
Temporary Services
Sick/Fit Note
Vaccinations
Wasted Medications
Your Record
Update Your Details
Help & Support
News