Primary Care Liaison Service feedback form

Today's date *

Date of incident (if applicable)

Your Name *

Job Title *

Email address *

Contact number *

GP Surgery *

Patient NHS number or MRN (if applicable)

Details of the clinical service

The name of the service (if known)

Please describe the interface issue, including: *

What was requested or expected? Why do you believe this should have been managed by secondary care? Any other relevant information

Do you have any suggestions to prevent recurrence of this issue? (Optional)

*

Preparing for your visit with us: Before you arrive, during your stay and how we'll look after you