The Guildhall and Barrow Surgery
Signing up for our Patient Reference Group

If you are happy for us to contact you periodically by e-mail, please print this page, enter your details in all fields and return the form to the practice.
 
Name:
Email address:
Post code:
The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.  Please tick each box that applies to you.
Your gender: Male: Female:
Your age: Under 16: 17 - 24:
  25 - 34: 35 - 44:
  45 - 54: 55 - 64:
  65 - 74: 75 - 84:
  Over 84:  
The ethnic background with which you most closely identify with is:
White British Group: Irish:
Mixed White & black Caribbean: White & black African:
  White & Asian:  
Asian or Asian British Indian: Pakistani:
  Bangladeshi:  
Black or Black British Caribbean: African:
Chinese or Other Chinese: Any Other:
How would you describe how frequently you come to the practice?
Regularly Occasionally Very rarely
Please note that we will not respond to any medical information or questions received through our survey.

Thank you.