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* 1. How satisfied are you with the care you receive at the surgery?

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* 2. How satisfied are you with the service the dispensary provide (if applicable)

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* 3. Would you recommend the surgery to someone who has just moved to the local area?

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* 4. Do you have any other comments or feedback you would like to share with us?

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* 5. Do You have any visual or hearing impairments for which you require support, such as hearing loop, language line?

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* 6. If you have a carer responsibilities for anyone in your household with a long standing health problem or disability please ask reception for a carers form.

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* 7. Are you male or female

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* 8. What age group are you in?

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* 9. What is your ethnicity? (Please select all that apply.)

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