Relocation of Belsize Priory Medical Practice to Abbey Road Re-development

1. What is your name?

Name

2. What is your email address?

If you enter your email address then you will automatically receive an acknowledgement email when you submit your response.

Email

3. Do you support this proposal?

Yes No Don’t Know

If you answered ‘no’ to the question please explain why?

4. Will you be willing to travel 100 metres (0.06 miles) from where you currently access GP services?

Yes No Don't know

If you answered ‘no’ to the question please explain why?

5. If the Practice relocates to a site 100 metres (0.06 miles) from where you currently access GP services, how would you travel there?

Walk Bus Train Tube Car Cycle Other

6. What is your postcode?

Postcode

7. Are you a patient or carer?

Patient Carer

8. Do you consider yourself to have a disability or a long-term health condition?

Yes No

9. What is your gender?

Male Female Other

10. What is your age bracket?

Under 24 25 - 50 51 - 74 Over 75

11. Any other information we need to take into consideration?

Any other information we need to take into consideration

12. Which race or ethnicity best describes you? (Please select one button only)

White:English,Welsh,Scottish,Nthn Irish or British White: Irish White: Gypsy or Irish Traveller White: Polish Any other White background Mixed/Multiple ethnic: White and Black Caribbean Mixed/Multiple ethnic: White and Black African Mixed/Multiple ethnic: White and Asian Any other Mixed or Multiple ethnic background Asian or Asian British: Indian Asian or Asian British: Pakistani Asian or Asian British: Bangladeshi Any other Asian background Chinese or other ethnic group: Chinese Black/African/Caribbean or Black British: African Black/African/Caribbean/Black British: Caribbean Any other Black, African or Caribbean background Other ethnic group: Arab Any other ethnic group

If any other ethnic group please specify

13. Any further comments that you have on the relocation of Belsize Priory Medical Practice to the new site?

Any comment?

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Introduction