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Communication consent

Let us know that you are happy to be contacted by the practice.

Thinking about your GP practice...

Overall, how was your experience of our service?(Required)

Very good

Good

Neither good nor poor

Poor

Very poor

Don’t know

Please can you tell us why you gave your answer?

Please tell us about anything that we could have done better

A little bit about you

Please note - completing this additional information is optional but helpful to the NHS in understanding the needs and experiences of individual patients.

Are you?

Male

Female

Prefer not to say

Prefer to self describe

Please let us know how you prefer to self describe

What age are you?

0 - 15

16 - 24

25 - 34

35 - 44

45 - 54

55 - 64

65 - 74

75 - 84

85 +

Do you consider yourself to have a physical or mental health condition or disability?

Yes

No

Please let us know more about your condition or disability

Which of the following best describes your ethnic background?

Please select your ethnic background

Asian or Asian British - Indian

Asian or Asian British - Pakistani

Asian or Asian British - Bangladeshi

Asian or Asian British - Chinese

Other Asian or Asian British background

Black or Black British - Caribbean

Black or Black British - African

Other Black or Black British background

Mixed British - White and Black Caribbean

Mixed British - White and Black African

Mixed British - White and Asian

Other Mixed British background

White - British

White - Irish

Other White background

Other ethnic background

I would rather not say

Please let us know your ethnic background

Are you?

the patient

the parent or carer

the patient and parent/carer

If you DO NOT wish your anonymous comments to be shared then please tick here

I DO NOT wish my comments to be shared

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 60 days calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Date published: 29th May, 2024
Date last updated: 19th February, 2026

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