Friends and Family Community
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Your feedback about your experience and quality of care is important to us. This survey will just take a few minutes to complete and we will use your feedback to better understand what is important to you, what we are doing well and where can make improvements.
Referral Form
Medical History
Alerts
Friends and Family Community
is required
Date of Appointment
Date of Appointment is required
Clinic/Service
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Clinic/Service is required
Are you the patient or the patients representative?
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Are you the patient or the patients representative? is required
Thinking about the service we provide
is required
Overall, how was your experience of our service?
Very Good
Good
Neither good nor poor
Poor
Very poor
Dont know
Overall, how was your experience of our service? is required
Please can you tell us why you gave your answer?
Please can you tell us why you gave your answer? is required
We are committed to ensuring that everyone has equal access to our services. We would like your help to do this by answering a few questions about your background. The information will be used to improve the quality of our services.
is required
Do you wish to complete these questions?
Yes
No
Do you wish to complete these questions? is required
Demographics
Which of the following options best describes how you think of yourself?
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Which of the following options best describes how you think of yourself? is required
What age are you?
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What age are you? is required
What is your ethnic group?
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What is your ethnic group? is required
Do you have a disability (any issue or impairment which is likely to last more than 12 months and impact on your ability to carry out everyday activities)?
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Do you have a disability (any issue or impairment which is likely to last more than 12 months and impact on your ability to carry out everyday activities)? is required
Which of the following options best describe how you think of yourself?
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Which of the following options best describe how you think of yourself? is required
Is your gender the same as it was assigned at birth?
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Is your gender the same as it was assigned at birth? is required
What is your religion or belief, even if you are not currently practising?
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What is your religion or belief, even if you are not currently practising? is required
Please tick this box if you do not wish your comments to be made public
