PPG Signing Up For Patient Reference Group If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us. OK Title Question Title * 1. Title Mr Mrs Miss Ms Other OK Please provide the following: Question Title * 2. Please provide the following: Name ZIP/Postal Code Email Address Phone Number OK Date of Birth* Question Title * 3. Date of Birth* OK Your Gender Question Title * 4. Your Gender Male Female Prefer Not To Say OK Your Age: Question Title * 5. Your Age: Under 16 17-24 25-34 35-44 45-54 55-64 65-74 74+ OK The ethnic background with which you most closely identify is: Question Title * 6. The ethnic background with which you most closely identify is: White Mixed Asian or Asian British Black or Black British Chinese or Other British Group White & Black Carribbean White & White Asian Indian Bangladeshi Caribbean Chinese Irish White & Black African Pakistani African Any Other OK How would you describe how often you come to the practice? Question Title * 7. How would you describe how often you come to the practice? Regularly Occasionally Very rarely OK DONE