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Foundation Surgery NHS GP surgery

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PPG registration

Form summary

How would you describe how often you come to the surgery? *

Regularly

Occasionally

Very rarely

What is your ethnic group? *

White: English, Welsh, Scottish, Northern Irish or British

White: Irish

White: Gypsy or Irish Traveller

White: Roma

White: Any other White background

Mixed or multiple ethnic groups: White and Black Caribbean

Mixed or multiple ethnic groups: White and Black African

Mixed or multiple ethnic groups: White and Asian

Mixed or multiple ethnic groups: Any other Mixed or multiple ethnic group background

Asian or Asian British: Indian

Asian or Asian British: Pakistani

Asian or Asian British: Bangladeshi

Asian or Asian British: Chinese

Asian or Asian British: Any other Asian background

Black, Black British, Caribbean or African: Caribbean

Black, Black British, Caribbean or African: African

Black, Black British, Caribbean or African: Any other Black, Black British, Caribbean or African background

Other ethnic group: Arab

Other ethnic group: Any other ethnic group

Prefer not to say

What is your age group? *

Under 16

17 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 to 84

Over 84

Terms and conditions *

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.

If you are human, leave this field blank.

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