GREAT LUMLEY SURGERY PATIENT REFERENCE GROUP

 

Are you interested in joining a PATIENT REFERENCE GROUP?

 

We are encouraging patients to give their views about how the practice is doing. We would like to be able to find out the opinions of as many patients as possible and are asking if people they would like to provide their email addresses so we can contact you by email every now and again to ask you a question or two.

 

If you are happy for us to contact you by email please leave your details below and hand form back to reception.

 

NAME:

DOB:

EMAIL ADDRESS:

POSTCODE:

 

The additional information will help to make sure we try to speak to a representative sample of the patients that are registered at this practice.

 

Are you?   MALE       o                       FEMALE     o

 

Age Group     

Under 16

o

17 – 24

o

25 – 34

o

35 – 44

o

45 – 54

o

55 – 64

o

65 – 74

o

75 - 84

o

Over 84

o

 

To help us ensure our contact list is representative of our local community please indicate which of the following ethnic background you would closely identify with.

 

ETHNIC ORIGIN

A. WHITE                             B. MIXED                                                           C. ASIAN OR ASIAN BRITISH

British          o                       White and Black Caribbean       o                  Indian              o

Irish             o                        White and Black Africa             o                  Pakistani          o

Any other    o                       Any other mixed background    o                 Bangladeshi    o

                                                                                                                              Any other Asian background                                                                                                                                           (within C)  o

D. BLACK OR BLACK BRITISH                                                 E. OTHER ETHNIC GROUP

Caribbean    o                                                                                                      Chinese                            o

African       o                                                                                                       Any other ethnic group   o

Any other black background   o

(within D)

 

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

 

REGULARLY o                      OCCASIONALLY o              VERY RARELY o

 

Please note that no medical information or questions will be responded to.

 

The information you supply us will be used lawfully in accordance with the Data Protection Act 1998. The DPA 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.

 

THANK YOU.

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