Patient Reference Group Survey

With Carers In Mind

Lodge Surgery is proud to have been awarded the Gold Plus Standard Award by

Carers Support Wiltshire for the last 3 years for our work with our carers.

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* 1. Please tick if you are 18 years of age or under?

Yes I am 18 or under

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* 2. Are you:

Male?

Female?

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* 3. Did you know if you care for someone who relies on you to look after their basic needs on a day to day basis you are probably a “Carer”?

Yes

No

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* 4. Are you a Carer?

Yes

No

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* 5. Did you know Lodge Surgery has a Carers’ Register? (Forms are available in Reception.)

Yes

No

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* 6. Did you know if you are a Carer, and you join our Register, the following services are available to you? Please tick all you know about.

Flexible appointment

Flu vaccination

£50 carer's break voucher

Carers' clinics and nurse check up

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* 7. Did you know the following organisations can offer help to you and your cared for person? Please tick all you know about.

Carers Support Wiltshire

Young Carers

Spurgeons

Fun for All

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* 8. If you would like to be added to our register or would like to receive more information on any of these services please leave your name and address: