Have Your Say.

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Usual Surgery

Haresfield Surgery

Kempsey Surgery

Your Gender

Male

Female

The ethnic background with which you most closely identify is:

White - British

White - Irish

Mixed - White & Black Caribbean

Mixed - White & Asian

Mixed - White & Black African

Asian or Asian British - Bangladeshi

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Black or Black British - Caribbean

Black or Black British - African

Chinese

Other

Are you a parent looking after children up to the age of 16 years at home? *

Yes

No

Are you a retired person? *

Yes

No

Are you a single parent? *

Yes

No

Are you disabled? *

Yes

No

Are you a Carer (somebody who looks after or supports a relative or friend)? *

Yes

No

Do you have a long-term health condition? *

Yes

No

How often do you come to the practice? *

Regularly

Occasionally

Very rarely

Would you be able to attend the regular meeting once a month - usually 3rd Tuesday 5pm - 7pm? *

Yes

No

Privacy Policy *

This form collects your name, date of birth, email, other personal information and medical details which you enter. We use Squarespace as our website provider and any information you enter into this form is also processed by them in accordance with GDPR and forwarded to Haresfield & Kempsey's NHS email address. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS.

I consent to the practice collecting and storing my data from this form.