Patient Participation Group

Title: * Select one... Mr Mrs Miss Ms

Post code: *

First name: *

Last name: *

Email: *

Telephone: *

Gender: Select one... Male Female Transgender

Age: Select one... Under 16 17 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 Over 84

Your ethnic origin: Select one... 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?: Select one... Regularly Occasionally Very Rarely

PRG sign up options: Select one... Face-To-Face Virtual Both the above