Copy of Contact form - VOCHS feedback forum

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If you are happy for us to contact you from time to time, please fill and submit this form.

So help us contact you, please provide us with your name, postcode, email address and telephone number in the boxes provided.

* What is your name ?

* What is your postal code ?

What is your email address ?

* What is your telephone number ?

The following additional information will help us make sure we communicate with a representative sample of our patient population:

* Are you ?

Male

Female

* Age Group ?

To help us ensure our contact list is representative of our local community please indicate which ethnic background you most identify with:

White

Asian or Asian British

Black or Black British

Mixed

Chinese

Other - Please type your ethnicity (if not provided) in box provided

To help us ensure our contact list is representative of our local community please indicate which of the following most closely identify with:

* Employment Status

* Do you have a carer or care for someone?

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

If you would like to be more involved with the forum and help co-ordinate please indicate here:

*

I would like to help co-ordinate the forum

I would NOT like to help co-ordinate the forum

If you have any queries about the forum, please goto our website www.chawtonhousesurgery.co.uk or email hamp-pct.chawtonhouse@nhs.net.

Please note that no medical information or questions will be responded to.

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.

* Indicates Response Required

Under 16	17-24
25-34	35-44
45-54	55-64
65-74	75-84
85 and over