The information below will help us to make sure that we receive feedback from a representative
sample of the patients registered at this practice.
Filed marked with red asterisk are compulsory *. The information you supply 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 in held about you, and sets
out rules to make sure that the information is held properly.
Please note that by urine this form you will be sending information yourself across
the Internet, whilst ever 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 than you should you another method of registration.