{"id":3435,"date":"2019-03-17T11:41:34","date_gmt":"2019-03-17T11:41:34","guid":{"rendered":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/?page_id=3435"},"modified":"2023-05-03T16:43:50","modified_gmt":"2023-05-03T15:43:50","slug":"signing-up-for-patient-reference-group","status":"publish","type":"page","link":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/about-us\/contact\/signing-up-for-patient-reference-group\/","title":{"rendered":"Signing Up For Patient Participation Group"},"content":{"rendered":"<link rel='stylesheet' id='formidable-css' href='https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-content\/plugins\/formidable\/css\/formidableforms.css?ver=4271720' media='all' \/>\n<div class=\"frm_forms  with_frm_style frm_style_big_text\" id=\"frm_form_38_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_hnlsj6315\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Signing Up For Patient Participation Group<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"38\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_38\" id=\"frm_hide_fields_38\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"hnlsj6315\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_38\" name=\"frm_submit_entry_38\" value=\"034b284f37\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/3435\" \/><div id=\"frm_field_919_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio frm_other_container\">\r\n    <div  id=\"field_7x33o_label\" class=\"frm_primary_label\">Title\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_7x33o_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_919-0\"><label for=\"field_7x33o-0\">\t\t<input type=\"radio\" name=\"item_meta[919]\" id=\"field_7x33o-0\" value=\"Mr\"\n\t\t   data-reqmsg=\"Title cannot be blank.\" data-invmsg=\"Title is invalid\" aria-invalid=\"false\"  \/> Mr<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_919-1\"><label for=\"field_7x33o-1\">\t\t<input type=\"radio\" name=\"item_meta[919]\" id=\"field_7x33o-1\" value=\"Mrs\"\n\t\t   data-reqmsg=\"Title cannot be blank.\" data-invmsg=\"Title is invalid\" aria-invalid=\"false\"  \/> Mrs<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_919-2\"><label for=\"field_7x33o-2\">\t\t<input type=\"radio\" name=\"item_meta[919]\" id=\"field_7x33o-2\" value=\"Miss\"\n\t\t   data-reqmsg=\"Title cannot be blank.\" data-invmsg=\"Title is invalid\" aria-invalid=\"false\"  \/> Miss<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_919-4\"><label for=\"field_7x33o-4\">\t\t<input type=\"radio\" name=\"item_meta[919]\" id=\"field_7x33o-4\" value=\"Miss\"\n\t\t   data-reqmsg=\"Title cannot be blank.\" data-invmsg=\"Title is invalid\" aria-invalid=\"false\"  \/> Miss<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_919-other_5\"><label for=\"field_7x33o-other_5\">\t\t<input type=\"radio\" name=\"item_meta[919]\" id=\"field_7x33o-other_5\" value=\"Other\"\n\t\t   data-reqmsg=\"Title cannot be blank.\" data-invmsg=\"Title is invalid\" aria-invalid=\"false\"  \/> Other<\/label><label for=\"field_7x33o-other_5-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_7x33o-other_5-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][919]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_920_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_xu1tj6314\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xu1tj6314\" name=\"item_meta[920]\" value=\"\"  data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_921_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_xt7az6314\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xt7az6314\" name=\"item_meta[921]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_922_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ppbxb6314\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ppbxb6314\" name=\"item_meta[922]\" value=\"\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_ppbxb6314\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_ppbxb6314\">Enter Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_conf_922_container\" class=\"frm_form_field frm_none_container frm_conf_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_conf_ppbxb6314\" class=\"frm_conf_label frm_primary_label\">Confirm Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_conf_ppbxb6314\" name=\"item_meta[conf_922]\" value=\"\"  placeholder=\"Please confirm your email\" data-reqmsg=\"Confirm Email cannot be blank.\" aria-required=\"true\" data-confmsg=\"The entered values do not match\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_conf_ppbxb6314\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_conf_ppbxb6314\">Confirm Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_923_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third  frm4 frm_first\">\r\n    <label for=\"field_w1eya6314\" class=\"frm_primary_label\">Date of birth\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_w1eya6314\" name=\"item_meta[923]\" value=\"\"  data-frmmask=\"99\/99\/9999\" placeholder=\"DD\/MM\/YYYY\" data-reqmsg=\"Date of birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\\/\\d\\d\\\/\\d\\d\\d\\d$\"   aria-describedby=\"frm_desc_field_w1eya6314\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_w1eya6314\">Please use format day\/month\/year e.g. 12\/05\/1979<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_924_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third frm4\">\r\n    <label for=\"field_spq8l4314\" class=\"frm_primary_label\">Phone Number\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_spq8l4314\" name=\"item_meta[924]\" value=\"\"  data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_2058_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_third vertical_radio\">\r\n    <div  id=\"field_xh40e_label\" class=\"frm_primary_label\">Consent to contact you\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_xh40e_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_2058-0\"><label for=\"field_xh40e-0\">\t\t<input type=\"radio\" name=\"item_meta[2058]\" id=\"field_xh40e-0\" value=\"I consent to be contacted by SMS\"\n\t\t   data-invmsg=\"Consent to contact you is invalid\" aria-invalid=\"false\"  \/> I consent to be contacted by SMS<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_2058-1\"><label for=\"field_xh40e-1\">\t\t<input type=\"radio\" name=\"item_meta[2058]\" id=\"field_xh40e-1\" value=\"I decline consent to be contacted by SMS\"\n\t\t   data-invmsg=\"Consent to contact you is invalid\" aria-invalid=\"false\"  \/> I decline consent to be contacted by SMS<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_925_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this Practice.<\/h3>\r\n\r\n\r\n<div id=\"frm_field_926_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio frm_other_container\">\r\n    <div  id=\"field_jq65x_label\" class=\"frm_primary_label\">Your Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_jq65x_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_926-925-0\"><label for=\"field_jq65x-0\">\t\t<input type=\"radio\" name=\"item_meta[926]\" id=\"field_jq65x-0\" value=\"Male\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your Gender cannot be blank.\" data-invmsg=\"Your Gender is invalid\" aria-invalid=\"false\"  \/> Male<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_926-925-1\"><label for=\"field_jq65x-1\">\t\t<input type=\"radio\" name=\"item_meta[926]\" id=\"field_jq65x-1\" value=\"Female\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your Gender cannot be blank.\" data-invmsg=\"Your Gender is invalid\" aria-invalid=\"false\"  \/> Female<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_926-925-2\"><label for=\"field_jq65x-2\">\t\t<input type=\"radio\" name=\"item_meta[926]\" id=\"field_jq65x-2\" value=\"Prefer not to say\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your Gender cannot be blank.\" data-invmsg=\"Your Gender is invalid\" aria-invalid=\"false\"  \/> Prefer not to say<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_926-925-other_3\"><label for=\"field_jq65x-other_3\">\t\t<input type=\"radio\" name=\"item_meta[926]\" id=\"field_jq65x-other_3\" value=\"Other\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your Gender cannot be blank.\" data-invmsg=\"Your Gender is invalid\" aria-invalid=\"false\"  \/> Other<\/label><label for=\"field_jq65x-other_3-otext\" class=\"frm_screen_reader frm_hidden\">Other<\/label><input type=\"text\" id=\"field_jq65x-other_3-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][926]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_927_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_three_col\">\r\n    <div  id=\"field_t0ann_label\" class=\"frm_primary_label\">Your age\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_t0ann_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-0\"><label for=\"field_t0ann-0\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-0\" value=\"Under 16\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/> Under 16<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-1\"><label for=\"field_t0ann-1\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-1\" value=\"17 - 24\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/> 17 &#8211; 24<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-2\"><label for=\"field_t0ann-2\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-2\" value=\"25 -34\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/> 25 -34<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-4\"><label for=\"field_t0ann-4\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-4\" value=\"35 -44\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/> 35 -44<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-7\"><label for=\"field_t0ann-7\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-7\" value=\" 45 - 54\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/>  45 &#8211; 54<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-11\"><label for=\"field_t0ann-11\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-11\" value=\"55 - 64\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/> 55 &#8211; 64<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-16\"><label for=\"field_t0ann-16\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-16\" value=\"65 - 74\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/> 65 &#8211; 74<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-22\"><label for=\"field_t0ann-22\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-22\" value=\"75 - 84\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/> 75 &#8211; 84<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_927-925-29\"><label for=\"field_t0ann-29\">\t\t<input type=\"radio\" name=\"item_meta[927]\" id=\"field_t0ann-29\" value=\"Over 84\"\n\t\t   data-sectionid=\"925\" data-reqmsg=\"Your age cannot be blank.\" data-invmsg=\"Your age is invalid\" aria-invalid=\"false\"  \/> Over 84<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_929_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">The ethnic background with which you most closely identify is:<\/h3>\r\n\r\n\r\n<div id=\"frm_field_930_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_two_col\">\r\n    <div  id=\"field_9flo0_label\" class=\"frm_primary_label\">Your ethnic background\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_9flo0_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-0\"><label for=\"field_9flo0-0\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-0\" value=\"White British\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> White British<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-1\"><label for=\"field_9flo0-1\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-1\" value=\"White Irish\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> White Irish<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-2\"><label for=\"field_9flo0-2\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-2\" value=\"Mixed White &amp; Black Caribbean\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Mixed White &amp; Black Caribbean<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-4\"><label for=\"field_9flo0-4\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-4\" value=\"Mixed White &amp; Black African\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Mixed White &amp; Black African<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-7\"><label for=\"field_9flo0-7\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-7\" value=\"Mixed White &amp; Asian\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Mixed White &amp; Asian<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-11\"><label for=\"field_9flo0-11\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-11\" value=\"Indian - Asian or Asian British\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Indian &#8211; Asian or Asian British<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-16\"><label for=\"field_9flo0-16\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-16\" value=\"Pakistani - Asian or Asian British\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Pakistani &#8211; Asian or Asian British<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-22\"><label for=\"field_9flo0-22\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-22\" value=\"Bangladeshi - Asian or Asian British\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Bangladeshi &#8211; Asian or Asian British<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-29\"><label for=\"field_9flo0-29\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-29\" value=\"Caribbean - Black or Black British\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Caribbean &#8211; Black or Black British<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-37\"><label for=\"field_9flo0-37\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-37\" value=\"African - Black or Black British\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> African &#8211; Black or Black British<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-38\"><label for=\"field_9flo0-38\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-38\" value=\"Chinese \"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Chinese <\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-40\"><label for=\"field_9flo0-40\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-40\" value=\"Any other\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Any other<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_930-929-41\"><label for=\"field_9flo0-41\">\t\t<input type=\"radio\" name=\"item_meta[930]\" id=\"field_9flo0-41\" value=\"Prefer not to say\"\n\t\t   data-sectionid=\"929\" data-reqmsg=\"Your ethnic background cannot be blank.\" data-invmsg=\"Your ethnic background is invalid\" aria-invalid=\"false\"  \/> Prefer not to say<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_932_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">How would you describe how often you come to the Practice?<\/h3>\r\n\r\n\r\n<div id=\"frm_field_933_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_three_col\">\r\n    <div  id=\"field_erbp8_label\" class=\"frm_primary_label\">You attend the Practice\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_erbp8_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_933-932-0\"><label for=\"field_erbp8-0\">\t\t<input type=\"radio\" name=\"item_meta[933]\" id=\"field_erbp8-0\" value=\"Regularly\"\n\t\t   data-sectionid=\"932\" data-reqmsg=\"You attend the Practice cannot be blank.\" data-invmsg=\"You attend the Practice is invalid\" aria-invalid=\"false\"  \/> Regularly<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_933-932-1\"><label for=\"field_erbp8-1\">\t\t<input type=\"radio\" name=\"item_meta[933]\" id=\"field_erbp8-1\" value=\"Occasionally\"\n\t\t   data-sectionid=\"932\" data-reqmsg=\"You attend the Practice cannot be blank.\" data-invmsg=\"You attend the Practice is invalid\" aria-invalid=\"false\"  \/> Occasionally<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_933-932-2\"><label for=\"field_erbp8-2\">\t\t<input type=\"radio\" name=\"item_meta[933]\" id=\"field_erbp8-2\" value=\"Very Rarely\"\n\t\t   data-sectionid=\"932\" data-reqmsg=\"You attend the Practice cannot be blank.\" data-invmsg=\"You attend the Practice is invalid\" aria-invalid=\"false\"  \/> Very Rarely<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_935_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Privacy Policy<\/h3>\r\n\r\n\r\n<div id=\"frm_field_936_container\" class=\"frm_form_field  frm_html_container form-field\">This form collects your name, date of birth, email, other personal information and medical details. 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. Please read our <a href=\"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/about-us\/practice-policies\/patient-record\/how-we-use-your-data\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a> to discover how we protect and manage your submitted data.<\/div>\n<div id=\"frm_field_937_container\" class=\"frm_form_field form-field  frm_required_field frm_inline_container vertical_radio\">\r\n    <label for=\"field_4oeoa4\" class=\"frm_primary_label\"> \r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_937-935-0\"><label for=\"field_4oeoa4-0\"><input type=\"checkbox\" name=\"item_meta[937][]\" id=\"field_4oeoa4-0\" value=\"I consent to the Practice collecting and storing my data from this form.\"  data-sectionid=\"935\" data-reqmsg=\"We need your consent to proceed. Please tick the box to consent.\" data-invmsg=\"  is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I consent to the Practice collecting and storing my data from this form.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__653009dd87f9e\">\n\t\t\t\t<label for=\"frm_email_38\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_38\" type=\"text\" class=\"frm_verify\" name=\"frm__653009dd87f9e\" value=\"\" autocomplete=\"false\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"lifoapthe8ZNvMVms8\/tU6z+V28lLP\/AVxcjiyrl7uw=\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Send<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":6577921,"featured_media":0,"parent":1270,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_uag_custom_page_level_css":"","footnotes":"","_links_to":"","_links_to_target":""},"acf":[],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false,"mailpoet_newsletter_max":false},"uagb_author_info":{"display_name":"Editor","author_link":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/author\/gary-genpra\/"},"uagb_comment_info":0,"uagb_excerpt":null,"publishpress_future_action":{"enabled":false,"date":"2024-05-04 22:33:51","action":"change-status","newStatus":"draft","terms":[],"taxonomy":""},"_links":{"self":[{"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/pages\/3435"}],"collection":[{"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/users\/6577921"}],"replies":[{"embeddable":true,"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/comments?post=3435"}],"version-history":[{"count":1,"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/pages\/3435\/revisions"}],"predecessor-version":[{"id":8293,"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/pages\/3435\/revisions\/8293"}],"up":[{"embeddable":true,"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/pages\/1270"}],"wp:attachment":[{"href":"https:\/\/www.stphilipsmedicalcentre.nhs.uk\/wp-json\/wp\/v2\/media?parent=3435"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}