Exit Merger patient feedback form Page 1 Question Title * 1. Do you support this proposal? Yes No I don't know Question Title * 2. Will you be willing to travel 1.5 miles from where you currently access GP services? Yes No I don't know Question Title * 3. If the Practice relocates to a site 1.5 miles from where you currently access GP services, how would you travel there? Walk Car Bus Cycle Train Tube Other (please specify) Question Title * 4. What is your postcode Question Title * 5. Are you a patient or carer Patient Carer Both Question Title * 6. Do you consider yourself to have a disability or a long-term health condition? Yes No Question Title * 7. What is your gender Male Femal Other (please specify) Question Title * 8. What is your age bracket Under 24 25-50 51-74 Over 75 Question Title * 9. Ethnicity Question Title * 10. Please use the space below to let us know any thoughts you have regarding the relocation of Derwent medical practice Done