Sign Up to the Patient Group Back to the main index Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Email(Required) Phone(Required)Gender(Required)Please Select...MaleFemaleOtherAge(Required)Please Select...Under 1617-2425-3435-4445-5455-6464-7475-84Over 84Security Question (used to identify you)(Required)Please Select...In which month did you last see a doctor/nurse at this surgery?Do you take any prescribed medicines? Can you tell me what they are?Have you had an operation in hospital? Can you remember when and what it was for?Answer(Required)Ethnicity(Required)Please Select...White BritishWhite IrishOther WhiteBlack CaribbeanBlack AfricanOther BlackBlack Caribbean and WhiteBlack African and WhiteOther MixedIndianPakistaniBangladeshiOther AsianI do not wish to stateOther ethnic groupHow often do you come to the practice?: *Please Select...RegularlyOccasionallyRarelyVery RarelyWhat can you bring to the Patient Group - Ideas / Suggestions / Comments.:(Required)Consent(Required)This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form.(Required)