Triage Questionnaire

Have you used the online form for an appointment or enquiry

If no is this because:

You do not feel confident in filling out the form

If you are not confident in filling out the form you can contact the Digi Hub they will be able to help you. The Digi Hub is every Wednesday 11.30am to 1.30pm as a drop in service to help with the NHS App or access to our website.

If you have not used the form because you have not needed it please check this box.

If you have not completed the form because you have not needed to use it you do not need to fill in the rest of the questions

Do or did you need assistance with the form?

If you are need assistance with the form the Digi Hub will be able to help you. The Digi Hub is every Wednesday 11.30am to 1.30pm as a drop in service to help with the NHS App or access to our website.

How easy was it to complete the form?

When do or did you get a response to the form?

Do or did you feel that the response was what you needed?

Do you think that this system is better than the old one?

If yes please state why here:

If no please state why here:

In your opinion is there anything that could be changed to the current system to make it easier for patients

Please provide the following:

Your gender

Your age range:

Privacy Protection

Information entered into survey forms is used only for the purposes of processing your survey information and is stored and accessed securely by designated staff.

Issues raised in comments may be discussed between relevant members of staff. The information is used for quality monitoring purposes, in line with the expectations of those submitting the feedback.

Any personal information transmitted via survey forms may be anonymised when this is required to ensure compliance with General Data Protection Regulation.

This information is not shared with any external third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The London Road Surgery • Market House, Market Road, Wickford, Essex, SS12 0AA.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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