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Secure Surgery Website
From Wiggly-Amps Ltd
01263 834 648    info@wiggly-amps.com

Join Our Patient Reference Group

 

Any visitor to your website can choose to join your patient reference/participation group. They are required to answer some questions about themselves - see below. You are able to contact your members via email using your management area at any time. The answers provided by your members can help you contact certain types of patients only. For example, if you need to contact all female members only, or all members who are retired etc.

Title:
Forename *

Surname *

Date of Birth *
 Format: dd/mm/yyyy
Address *

Postcode *

E-mail address *

Mobile Phone Number

Phone Number *

Are you ? *

How old are you ? *

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

Are you a carer of one of our patients? .

Do you have any long-standing illness, disability or infirmity? By long-standing we mean anything that has troubled you over a period of time or that is likely to affect you over a period of time *

Which ethnic group do you belong to? *

Is your accommodation? *

Which of the following best describes you? *

What is your marital status? *

Please click the image of the rabbit below and a green border will appear around it. Then please continue down this page. If you are unsure please click here to try another challenge.

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GP Website from Wiggly-Amps Ltd. Total visitors:75031