If you are happy for us to contact you periodically by email please complete your details below.

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* 1. Please enter your full name

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* 2. Please enter your e-mail address (this information will be kept confidential)

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* 3. Please enter your postcode

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* 4. Are you male or female?

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* 5. Are you a carer?

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* 6. What is your age group?

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* 7. Which ethnic background best describes you?

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* 8. would you describe how often you come to the practice?

THANK YOU VERY MUCH FOR YOUR PARTICIPATION

Please note that no medical information or questions will be responded to.

The information you supply us with will be used lawfully, in accordance with the Data Protection Act 1988. The Data Protection Act 1988 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.

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