What is your ethnic group? White Mixed / Multiple ethnic groups ☐ ☐ Asian / Asian British Other ethnic group ☐ ☐ Black / African / Caribbean / Black British ☐ How old are you? About you 0 - 15 16 - 24 25 - 34 35 - 44 45 - 54 ☐ ☐ ☐ ☐ ☐ To help us understand your feedback we need to know a little more about who 55 - 64 65 - 74 75 84 85+ ☐ ☐ – ☐ ☐ you are and /or you might represent I am responding on behalf of I am a patient at the surgery Myself Yes No ☐ ☐ A group or organisation Please provide your postcode: Name of group or organisation, if applicable: Who does this group represent, if applicable? Based on the information you have read in the consultation document, do you understand the proposals? Yes No Unsure ☐ ☐ ☐ Option One (please select either Option 1 or Option 2) To close the premises at the Bargate Medical Centre and to relocate the clinical team at Telephone House Surgery ☐ Option Two To keep the premises open at the Bargate Medical Centre with a much reduced GP / Nurse service ☐ Are you male or female? Male Female ☐ ☐
About you To help us understand your feedback we need to know a little more about who you are and /or you might represent I am responding on behalf of I am a patient at the surgery Myself Yes ☐ No ☐ A group or organisation Please provide your postcode: Name of group or organisation, if applicable: Who does this group represent, if applicable? Based on the information you have read in the consultation document, do you understand the proposals? Yes ☐ No ☐ Unsure ☐ Option One (please select either Option 1 or Option 2) To close the premises at the Bargate Medical Centre and to relocate the clinical team at Telephone House Surgery ☐ Option Two To keep the premises open at the Bargate Medical Centre with a much reduced GP / Nurse service ☐ Are you male or female? Male ☐ Female ☐ What is your ethnic group? White ☐ Mixed / Multiple ethnic groups ☐ Asian / Asian British ☐ Other ethnic group ☐ Black / African / Caribbean / Black British ☐ How old are you? 0 - 15 ☐ 16 - 24 ☐ 25 - 34 ☐ 35 - 44 ☐ 45 - 54 ☐ 55 - 64 ☐ 65 - 74 ☐ 75 – 84 ☐ 85+ ☐
190503FullConsultation.docx