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This additional information will help to make sure we try to a representative sample of the patients registered at this practice

Are you male or female?

MaleFemale

What age group do you fall under?

Under1617-2425-3435-4445-5455-6465-7475-84over 84

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?

British GroupIrishWhite & Black CaribbeanWhite & Black AfricanWhite & AsianIndianPakistaniBangladeshiCaribbeanAfricanChineseAny Other

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

RegularlyOccasionallyVery rarely

Please leave us your contact details so we can get back to you with details

Name:

Telephone Number:

Email Address:

Date of Birth: