1. How likely are you to recommend our dental practice your friends and family if they needed similar care for treatment?
Extremely LikelyLikelyNeither Likely nor UnlikelyUnlikelyExtremely UnlikelyDon't Know
2. Thinking about your response to this question, what is the main reason why you feel this way?
3. Are you?
—Please choose an option—MaleFemale
4. What age are you?
Under 15 years16-2425-3435-4445-5455-6465-7475-8485+
5. Do you consider yourself to have a disability?
YesNo
5.1. Optional - provide further details about your disability:
6. Which of the following best describes your ethnic background?
BritishIrishOther white backgroundIndianPakistaniBangladeshiChineseOther Asian backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther mixed backgroundCaribbeanAfricanOther Black backgroundAnything else not listed hereI would rather not say
7. Are you? the patientthe parent or carerthe patient and parent/carer
8. Thank you for completing this form and providing us with anonymous feedback to improve our services.
We may share your anonymous comments to improve our service quality; please let us know if you do not wish this. Yes, share my anonymous commentsNo, do not share my anonymous comments
I consent to my data being handled per the Fox Lane Dental Care Privacy Policy
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