Gillingham Medical Practice - The Barn Surgery & Peacemarsh Surgery

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Gillingham Medical Practice

Signing Up For Our Practice Survey

If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.

Title	Mr Mrs Miss Ms
First Name(s)
Surname
Email Address
Postcode

The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.
Your Gender	Male	Female
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:
White	British Group	Irish
Mixed	White & Black Caribbean White & Black Asian	White & Black African
Asian or Asian British	Indian Bangladeshi	Pakistani
Black or Black British	Caribbean	African
Chinese or Other	Chinese	Any Other
How would you describe how often you come to the practice?
Regularly	Occasionally	Very Rarely
Which of the following areas are the most important to you?
Opening Hours	Telephone Contact	Clincal Care
Appointments	Waiting Room Facilities	Communication

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