Old Leake Medical Centre

This additional information will help to make sure we try to speak to a representative sample of the patients that are registered at this practice.

Are you? ^*
Male Female

Age group: ^*
(Please select your age group)
Please select: Under 16 17 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 Over 84

To help us ensure our contact list is representative of our local community please indicate which of the following ethnic backgrounds you would most closely identify with?

What is your ethnicity?: ^*
(Please select your ethnicity)
Please select: Please select: White: British White: Irish Mixed: White and Black Caribbean Mixed: White and Black African Mixed: White and Asian Asian Indian or British Indian Asian Pakistani or British Pakistani Asian Bangladeshi or British Bangladeshi Black Caribbean or British Caribbean Black African or British African Any other Black background Chinese Any other ethnic group