Harrold Medical Practice

Name*

First NameLast Name

Email*

example@example.com

Post Code*

Additional information

This 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*

MaleFemale

Age Group*

Ethnicity

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

What is your ethnicity?*

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

RegularlyOccasionallyVery rarely

Thank you

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 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.