Family and Friends Form

 

We would like you to think about your recent experiences of our service

How likely are you to recommend our GP practice to friends and family if they needed similar care or treatment?

 

Please tick one:

Extremely Likely                       □                      Likely                            □            

Neither Likely or Unlikely         □                      Extremely Unlikely        □

Don’t Know                             □

 

What do you like about our Practice?

 

………………………………………………………………………………

 

Can you suggest anything to improve our service?

 

………………………………………………………………………………

 

 

*Please tick this box if you DO NOT wish your comments to be made public   □

 

 

 

 

 

 

Ethnicity Monitoring

(optional)

White British/Irish

Mixed

Asian or Asian British

Black or Black British

Chinese

Other…………………

(please state)

Age Groups

(optional)

0-17 years

18-25 years

26-40 years

41-64 years

65+ years

Family and Friends Form

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.