We want to apologise for your poor experience. We aim to deliver a high level of service, and your feedback helps us to improve. You can post anonymously if you wish, or leave your details if you would like us to respond to you.

Poor Experience

Select Your Practice * Kings Road Medical Centre SW10 0UD Barlby Surgery W10 6DZ Cassidy Medical Centre SW6 5PX Randolph Surgery W9 1NH Earls Court Health & Wellbeing Centr SW5 OPT

When did your poor experience happen?

Start Date *

Start Time *

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End Date *

End Time *

121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM

Service Area

Please let us know what area of our service you had a poor experience with * Appointments Prescriptions Medical Care Communications Staff Premises Other

What happened?

In your own words, please tell us what happened *

How should we improve things?

Please let us know how we can help prevent your poor experience from happening again. *

Would you like us to respond to your feedback?

If you wish to post anonymously, please select No. If you wish to have a response, please select Yes, and then provide your contact details. *

Yes

No

Contact

Your contact details (if you wish to have a response)

You must fill in all of the fields below if you wish to have a response, we will be unable to respond without all of the information below.

Title *

Name *

Email

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Home Address *

Date of Birth *

How would you like us to contact you? * Email Letter Telephone

If you are human, leave this field blank.