My Friend Jen Prescription Payment Support Survey

This survey is for people living with any type of sickle cell, based in the UK, who pay for their prescriptions.

If you do not pay for your prescriptions, please do not complete this form.

Thank you for your understanding.

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* 1. How many different medications are you prescribed per month?

1 medication

2 medications

3 medications

4 or more medications

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* 2. Do you have any difficulty paying for your prescriptions?

Yes

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* 3. Have you ever purchased a PPC (NHS Prescription Prepayment Certificate)?

I have never heard of a PPC

No, I have never purchased a PPC

I can't afford A PPC

Yes, I purchase a PPC every 3 months

Yes, I purchase a PPC every year

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* 4. What area of the UK do you currently live in?

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* 5. Which race/ethnicity best describes you? (Please choose only one.)

Black / African

Black / Caribbean

Mixed Heritage

White / Caucasian

Multiple ethnicity / Other (please specify)

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* 6. What is your approximate average income per year?

< £10,000

£10,000 - £20,000

£20,000 - £30,000

> £30,000

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* 7. Would receiving financial support to pay for your prescriptions be beneficial to you?

Yes

My Friend Jen Prescription Payment Support Survey

Question Title

* 1. How many different medications are you prescribed per month?

Question Title

* 2. Do you have any difficulty paying for your prescriptions?

Question Title

* 3. Have you ever purchased a PPC (NHS Prescription Prepayment Certificate)?

Question Title

* 4. What area of the UK do you currently live in?

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* 5. Which race/ethnicity best describes you? (Please choose only one.)

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* 6. What is your approximate average income per year?

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* 7. Would receiving financial support to pay for your prescriptions be beneficial to you?

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* 8. If you answered yes to the previous question (Q7), please provide us with your name and best method of contact:

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* 9. Please explain how receiving financial support to pay for your prescriptions would help you.