PPG Sign-Up Form LinkedIn OptionalThis field is for validation purposes and should be left unchanged.At which surgery are you registered?Select…Kings Norton SurgeryAsh Tree SurgeryTitle Mr Mrs Miss Ms Mx Dr Other First Names OptionalSurname OptionalEmail Enter Email Confirm Email Contact NumberPostcodeDate of Birth Day Month Year The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.Gender Male Female Other Your Age Under 16 17-24 25-34 35-44 45-54 55-64 65-74 75-84 Over 84 The ethnic background with which you most closely identify is:How would you describe how often you come to the practice? Regularly Occasionally Very Rarely Non-urgent advice: Please NoteWe will not respond to any medical information or questions received through this survey.
