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* 1. Thinking about your recent appointment, overall, how was your experience of our service?

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* 2. How satisfied were you with the service you received when in contact with GP Care?

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* 3. How clear and easy was it to understand the information we provided about your appointment?

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* 4. How satisfied were you with the service you received at your appointment?

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* 5. How well did the appointment meet your choice of location?

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* 6. How well did the appointment meet your choice of time?

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* 7. Have you been treated with dignity and respect by GP Care?

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* 8. Please could you explain why you gave those answers?

Organisations that provide healthcare for the NHS are required to collect information about the patients who use its services.  The information on this form is collected to fulfil that obligation and to improve the services we provide.  It is used for monitoring purposes only and ensures we treat all patients from across the community equally. 
 
We will treat all personal information in line with current data protection legislation.  
 
This form is entirely confidential.  It is not traceable and does not affect the treatment you receive.  Completion of the form is voluntary but please return it even if it is not complete. 

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* 9. What is your gender?

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* 10. What is your age?

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* 11. What is your ethnic group?

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* 12. Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? (include any issues/problems related to old age)

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* 13. Which clinic location did you visit? (e.g. Hadwen Medical Centre)

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* 14. Name of the Clinician at your appointment

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* 15. Name of the Healthcare Assistant at your appointment

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* 16. How would you rate the cleanliness of the clinic?

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* 17. Date of your appointment

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