Your Experiences of Local Services
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1. Default Section
1
. Is the information you are providing:
Is the information you are providing:
An area of concern
A compliment
A suggestion for service improvement
2
. What is your issue/compliment/suggestion?
What is your issue/compliment/suggestion?
3
. This issue relates to
This issue relates to
My own experience
The experience of a friend/relative
The experience of a member/client of my group
4
. When did you experience this issue?
MM
DD
YYYY
Date
When did you experience this issue? Date Month
/
Day
/
Year
5
. Which category/categories does your issue or comment relate to?
Which category/categories does your issue or comment relate to?
Adult social care services
Primary & community health services (eg. GPs, dentists, pharmacists, optometrists, community nursers)
Hospital Services
Learning difficulities services
Services for older people
Mental health services
Carers' issues
Patient transport
Disability services and issues
6
. Does your issue/comment relate to any specific health premises?
Does your issue/comment relate to any specific health premises?
Hull Royal Infirmary (please specify below)
Castle Hill Hospital (please specify below)
GP Surgery (please specify below)
Dentist Surgery (please specify below)
Care home (please specify below)
Other (please specify below)
Please provide further details of premises
7
. Are you a member of the LINk?
Are you a member of the LINk?
Yes as an individual
Yes as part of a group
No
Don't know
8
. How did you hear about the LINk?
How did you hear about the LINk?
Word of mouth
Event/Forum
Website
Internet Search engine
Leaflet
Media
Other
If other please specify here
9
. If you are willing to be contacted by ourselves with regards to this issue, or would like to be involved in any future work on this issue, please leave your contact details here.
If you are willing to be contacted by ourselves with regards to this issue, or would like to be involved in any future work on this issue, please leave your contact details here.
Name
Address
Telephone
Email
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