Join our virtual Patient Group

First name

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Second name

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Email

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Post code

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Gender

Female

Male

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Date of birth

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Etnicity

-- select one --Prefer not to say British Irish Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed background Indian Pakistani Bangladeshi Any other Asian background African Caribbean Any other Black background Chinese Any other ethnic group

Frequency of visits

-- select one --Frequently Regularly Occasionally Rarely

SIGN ME UP

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The information you supply us will be used lawfully, in accordance with General Data Protection Regulations (GDPR) 2018. These regulations give you the right to know what information is held about you, and set out rules to make sure that this information is handled properly. 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. Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.