We would like you to think about your recent experiences of our service. 

Overall, how was your experience of our service?

□	Very Good
□	Good		
□	Neither good nor poor	
□	Poor
□	Very poor	
□	Don’t know		

What are your main reasons for choosing that response? Please tick as many responses as you feel appropriate

□	Level of confidence in the clinician	
□	Support given by surgery staff		
□	Quality of information available	
□	Ease of accessing the service		
□	Surgery facilities and premises		
□	Other						
PTO

It is a contractual requirement that all GP practices implement the NHS Friends and Family test (FFT). The precise wording of the question has been set by the Government and is intended to give patients the opportunity to provide feedback on their experience at the practice. Practices must submit data on the results to NHS England.

Please feel free to add any additional comments below 

About you

Are you?

□	Male			
□	prefer not to say
□	Female

Please identify your age group:

□	Under 16	
□	16 to 44
□	45 to 64
□	65 to 74
□	75 or over

Circumstances: please tick the most appropriate.

□	In Education 
□	In full Time Employment 	
□	In Part Time Employment	
□	Not Employed			
□	Retired	
□	Self Employed				
Thank you