Patient Reference Group Sign-Up Form PRG Sign-Up Form Name * Name First First Last Last Email Address * Phone Postcode 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 Transgender Rather not say Your Age * Please selectUnder 1617-2425-3435-4445-5455-6465-7475-84Over 84 The ethnic background with which you most closely identify is: White British Irish OtherOther Mixed White & Black Caribbean White & Black African White & Asian OtherOther Asian or Asian British Indian Pakistani Bangladeshi Chinese OtherOther Black or Black British Caribbean African OtherOther How would you describe how often you come to the practice? * Please selectRegularlyOccasionallyVery rarely If you are human, leave this field blank. Submit