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1. Choose the area of care you would like to tell us about *

GP services

Dentist

Pharmacies

Hospital inpatient (day treatment or overnight)

Hospital outpatients' appointments

Mental health support

Social care e.g. care homes, and home care

Accident and emergency/minor injury units

Ambulances and paramedics

NHS 111

Other (if other, please tell us which issue/service you are referring to)

2. Please tell us about your experience (For example, what went well? What could have been better?)

3. Does your feedback apply to a specific service? If so, please tell us which one(s).

4. How would you rate your care experience? *

5. In relation to this experience, please select what best describes you? *

I'm the person who received the care

I'm providing this feedback on behalf of a friend or relative, or because I'm their carer

Other

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By telling us more information about yourself, you will help us better understand how people's experiences may differ depending on their personal characteristics. However, if you do not wish to answer these questions you do not have to.

6. Please tell us your age

7. Please tell us which gender you identify with

8. Is your gender different to the sex you were assigned at birth?

9. Please tell us which sexual orientation you identify with

10. Please select your ethnicity

11. Please select which religion or belief you identify with

12. What is your partnership status?

13. Please select any of the following that apply to you:

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