Our Virtual Patient Participation Group PPG Sign Up Tittle * Mr Mrs Miss Ms Other Name * Surname * Date of Birth * Email * Telephone Number * Postcode * The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice. Gender * Male Female Other Your Age * Under 16 17-24 25-34 35-44 45-54 55-64 65-74 75-84 Over 84 How would you describe how often you come to the practice? Regularly Occasionally Very Rarely Are you a carer of one of our patients? Yes No Do you have any long-standing illness, disability or infirmity? By long-standing we mean anything that has troubled you over a period of time or that is likely to affect you over a period of time Yes No Which ethnic group do you belong to? White Black or Black British Asian or Asian British Mixed Chinese Other Ethnic Group Submit