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Survey on NHS Dental Provision

 

What sort of dental service do you use?

 

 NHS      Private     Emergency only      None 
 

What are the reasons for your choice? 

 

 Preference     Availability     Cost      Location   

Other
 

Where is your dental surgery?

 
 

How far is it from home?

 

 miles
 

If your current dentist is NHS:
 

Have you changed dentist in the last 10 years to stay with NHS?

 

 Yes       No
 

Did this involve extra expense/travel?

 

 Yes       No
If yes, give details
 

If you DON'T have an NHS dentist:
 

Have you lost NHS dental provision in the last 10 years?

 

 Yes       No
 

Have you tried to find one since?

 

 Yes       No
 

If NO please state reasons:

 
 

Do you have dependent children?

 

 Yes       No
 

If YES, what sort of dental services do they use?

 

 NHS    Private    Emergency only    None
 

What are your reasons?

 

 Preference   Availability    Cost    Location    Other
 

Which village do you live in?

 
 

If an NHS dentist opened in the area, would you switch?

 

 Yes       No
 

Any other comments?

 
 

Name:

 
 

Contact number:

 

You don't need to give us your name and contact number, however if you do, this information will remain confidential to the Bureau.

Thank you for your time in completing this survey.  This information will help us in our campaign to improve NHS dental provision in our local area.