Tree View Designs
Patient Participation Group
Personal details
Title: *
Select one...
Mr
Mrs
Miss
Ms
Post code: *
First name: *
Last name: *
Email: *
Telephone: *
Gender:
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Male
Female
Transgender
Age:
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Under 16
17 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 - 74
75 - 84
Over 84
Your ethnic origin:
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White (British Group)
White (Irish)
Mixed (White & Black Caribbean)
Mixed (White & Black African)
Mixed (White & Black Asian)
Asian or Asian British (Indian)
Asian or Asian British (Pakistani)
Asian or Asian British (Bangladeshi)
Black or Black British (Caribbean)
Black or Black British (African)
Chinese or Other (Chinese)
Chinese or Other (Any Other)
How often do you come to the practice?:
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Regularly
Occasionally
Very Rarely
Sign up options
PRG sign up options:
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Face-To-Face
Virtual
Both the above
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