FEEDBACK FORM We would like you to think about your recent experience of our service How likely are you to recommend our dental practice to friends and family if they needed similar care or treatment ? Extremely likelyLikelyNeither likely or unlikelyUnlikelyExtremely unlikelyDon't know Thinking about your response to this question, what is the main reason why you feel this way? A little bit about you: Are you? MaleFemale What age are you? 0-1516-2425-3435-4445-5455-6465-7475-8485+ Do you consider yourself to have a disability? YesNo Details: Which of the following best describes your ethnic background? White BritishIrishOther white background Asian or Asian British IndianPakistaniBangladeshiChineseOther Asian background Mixed White and Black CaribbeanWhite and Black AfricanWhite and Black AsianOther Mixed Background Black or Black British CaribbeanAfricanOther Black Background Other Anything elseI would rather not say Are you? The patientThe parent or carerThe patient and parent/carer Thank you for completing the form and providing us with feedback to improve our services. If you DO NOT wish your anonymous comments to be shared then please tick here:
