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Stack Garth | Brandon | Durham | DH7 8SJ | telephone 0191 378 2099

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Data Protection Act

Please note that we will not respond to any medical information or questions received through the survey. 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 sure that this information is handled properly.

Electronic Submission

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

 

Sign up to our Virtual Patient Participation Group

The practice wishes to expand on our current Patient Participation "Virtual Group" in order to consult with patients from time to time. This is in addition to the Practice Patient Participation Group. If you are happy for us to contact you via e-mail please complete this form. The information you supply will help to make sure we try to consult with a representative sample of patients registered at our practice and ensure our "Virtual Group" is representative of our local community.

Your Details
Title Mr Mrs Miss Ms
First Name
Surname
Email Address
Telephone
Street Address
Town
Postcode  

Your Gender Male Female

Your Age Under 16 yrs 17 - 24 yrs
  25 - 34 yrs 35 - 44 yrs
  45 - 54 yrs 55 - 64 yrs
  65 - 74 yrs 75 - 84 yrs
Over 84 yrs
Which of the following ethnic backgrounds would you most closely identify with?
White British Group Irish
Mixed White and Black Caribbean White and Black African
  White and Black Asian  
Asian or Asian British Indian Pakistani
  Bangladeshi  
Black or Black British Caribbean African
Chinese or Other Chinese Any Other
How often do you visit the practice?
Regularly Occasionally Rarely
Employment
Employed Unemployed Retired
School Student Student/Durham University  
Health
Are you a carer? Yes  
Are you responsible for anyone with learning disabilities? Yes  
Please indicate your health priorities