Contact Our PPG Title Mr Mrs Miss Ms Mx Dr Name First Last Date of Birth MM slash DD slash YYYY Email Address Phone NumberPostcode The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice. Your Gender Male Female Your Age Under 16 Optional 17 – 24 Optional 25 – 34 Optional 35 – 44 Optional 35 – 44 Optional 45 – 54 Optional 55 – 64 Optional 65 – 74 Optional 75 – 84 Optional Over 84 Optional The ethnic background with which you most closely identify is:Your ethnicity White Mixed Asian or Asian British Black or Black British Chinese or Other White British Group Optional Irish Optional Mixed White & Black Caribbean Optional White & Asian Optional White & Black African Optional Asian or Asian British Bangladeshi Optional Indian Optional Pakistani Optional Black or Black British Caribbean Optional African Optional Chinese or Other Chinese Optional Any Other Optional How would you describe how often you come to the practice?Please choose an option Regularly Occasionally Very Rarely