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* 1. Do you support this proposal?

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* 2. Will you be willing to travel 1.5 miles from where you currently access GP services?

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* 3. If the Practice relocates to a site 1.5 miles from where you currently access GP services, how would you travel there?

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* 4. What is your postcode

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* 5. Are you a patient or carer

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* 6. Do you consider yourself to have a disability or a long-term health condition?

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* 7. What is your gender

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* 8. What is your age bracket

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* 9. Ethnicity

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* 10. Please use the space below to let us know any thoughts you have regarding the relocation of Derwent medical practice

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