*1.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 need similar care or treatment?(Required.)

Extremely likely

Likely

Neither likely or unlikely

Unlikely

Extremely unlikely

Don't know

2.Are you male or female?

Male

Female

3.What age are you?

0-15

16-24

25-34

35-44

45-54

55-64

65-74

75-84

85+

4.Do you consider yourself to have a disability?  

Yes

No

5.Are you?

The patient

The parent or carer

6.Which of the following best describes your ethnic background?

White British

White Irish

White Other

Gypsy or Irish Traveller

White & Black Caribbean

White & Black African

White & Asian

Any other mixed or multiple background

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

British Black African

British Black Caribbean

Arab

Any other ethnic group