Patient Stories form

Your Name (required)

Your Email (required)

Health services used (required)

Please tell us in your own words about your experience of the health service you attended including dates and venues (within the last 12 months):

Your experience (required)

If you would like us to contact you to discuss your experience further or to arrange to tell us about your experience face to face, please provide your telephone number below:

Telephone number

Your Consent

We need to ensure that you are happy for us to use your story.

Please read the following statements and tick where applicable:

I am happy for Richmond CCG to use my story for any of the purposes detailed in section 7 of the patient stories information sheet or any purpose similar to those in section 7

OR

I am happy for Richmond CCG to use my story for the following purposes only (please tick):
Internal meetings/ committeesScreening at CCG public events with partners and members of the publicPublishing on the CCG websitePublications