Patient Reference Group Form Signing Up For Our Patient Reference GroupIf you are happy for us to contact you periodically by email please leave your details below and hand this form in at reception. Name OptionalEmail Address Optional Telephone OptionalPostcode OptionalThe information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.Your Gender Female Optional Male Optional Other Optional Prefer not to say Optional Your Gender Under 16 Optional 17 – 24 Optional 25 – 34 Optional 35 – 44 Optional 45 – 54 Optional 55 – 64 Optional 65 – 74 Optional 75 – 84 Optional Over 84 Optional The ethnic background which British (white) Optional Irish Optional Other (white) Optional White and Black Caribbean Optional White and Black African Optional White and Asian Optional Mixed other Optional Asian British Optional Indian Optional Pakistani Optional Bangladeshi Optional Asian other Optional British (black) Optional Caribbean Optional African Optional Black other Optional Chinese Optional Any other Optional How would you describe how often you come to the practice? Regularly Optional Occasionally Optional Very Rarely Optional Please note that we will not respond to any medical information or questions received through the survey.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