A little bit about you:
You don't have to answer any of the questions below, but if you do then any information that you provide
will be treated in the strictest confidence and will only be used to improve our services.
Are you?
What age are you?
Please select
15 or under
16-24
25-34
35-44
45-54
55-64
65-74
75-84
85 or over
Do you consider yourself to have a disability?
Please give brief details of your disability:
Which of the following best describes your ethnic background?
Please select
British
Irish
Other white background
Indian
Pakistani
Bangladeshi
Chinese
Other Asian background
Caribbean
African
Other Black background
White and Black Caribbean
White and Black African
White and Asian
Other Mixed background
Anything else
I would rather not say
Are you the patient, parent or carer?
Please select
The patient
The parent or carer
The patient and parent/carer
If you wish to comment on a specific appointment then please complete some or all of the fields below. If
you would like us to respond to your feedback then please also supply your name and email address.
Your name:
Your email address:
Who were you were treated by?
Not applicable
Peter Collins
Jeff Barlow
Martin McKenny
Giles Kidner
Janet Cowans
Julie Svenson
Your comments
Thank you for completing this form and providing us with feedback to improve our services.
