25May2013
Read our Privacy Statement
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Name: Address: Contact Email: Daytime Telephone? Mobile Telephone? How would you prefer to be contacted about the issue(s) you have raised on this form? Daytime telephoneMobile telephoneLetterEmailNo further contact Data Protection Statement
Wirral PCT will hold your information securely in accordance with the Data Protection Act (1998). We may need to share your information with our service providers to investigate your concern, Please tick here to confirm you are happy for us to use your information in this way. Tell us what you think Use this form to write down your thoughts and experience of using health services in Wirral and send it to us using the Send Request button at the bottom of the page. Please choose the option that best describes your comments (tick one box only): ComplimentComplaintOther comments Please provide comments, including as much detail as possible (e.g. if known, state names of staff who dealt with you, dates, locations etc.)
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