Name

First Name

Last Name

Would you be happy for your comments in sections A - D be made available anonymously on our website and relevant literature? *

We will NOT include ANY confidential or personally identifiable information such as your full name, home address or email address. We respect your privacy and preferences at all times and your decision will not affect the care you continue to receive from us.

Yes, you have permission to use my comments

No, please only use this internally

If you agree to allow us to use your comments, will you be happy for us to use any of the following details with your story:

Occupation

First name

Initials only

Gender

Age

Home town

Home county

None of the above thank you

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

Extremely likely

Likely

Neither likely nor unlikely

Unlikely

Extremely unlikely