Example form questions

Overall group title

Second label hint

As you’d write it on an envelope

Date of birth

For example 31 7 1961

A binary question?
Preferred method of contact

We’ll only contact you when it’s important.

Select one:

We’ll ask you to confirm this before you can use the service

We’ll ask you to confirm this before you can use the service

Create a password

Your password must have:

  • at least 4 characters
  • at least one number

Enter one or all of: a doctor’s name; practice name; address