If you are happy for us to contact you periodicaly by email please fill out all the fields below and send the completed form to us.  

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* 1. Title 

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* 2. Contact Information

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* 3. Your Gender

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* 4. Your Age

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* 5. What is your ethnicity? (Please select all that apply.)

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* 6. Do you have a disability

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* 7. How would you descibe how often you come to the practice?



About This Form

Fields marked with a red asterisk are compulsory.

The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make that this inforamtion is handled properly.

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