Wychall Lane Surgery
Patient participation group
(1/2 steps)
Full name
*
Surname
*
Email address
*
Contact number
Date of birth (For example, 31/3/1980)
*
Gender
Select gender
Male (including trans man)
Female (including trans woman)
Non-binary
Other (not listed)
Not Stated
Ethnic background
Select ethnic background
White British
White Irish
Mixed White & Black Caribbean
Mixed White & Black African
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
Other
How often do you come to practice?
Select any one
Regularly
Occasionally
Rarely
I agree that I am happy to be contacted occasionally via email. I agree to the
privacy policy.
*
Yes
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