Eclipse Pharmacy Healthwatch Waltham Forest

Email* (So you can be notified of provider responses and we can prevent spam, an email is required. Your email will be kept private and you will not be sent any marketing material. If you do not wish to add your email, please use info@healthwatchwalthamforest.co.uk)

I accept the Terms and conditions

I consent to being contacted regarding my feedback by Healthwatch*

Yes No

I confirm I am over the age of 16*

Yes No

I have parental consent*

Yes No

Subscribe to the newsletter? Yes, please sign me up No, I don't need this

If you are willing to provide us with some monitoring information please click here.

Please note: Monitoring information helps us identify trends and gaps in our information gathering, enabling us to provide more detailed evidence to service providers and commissioners about your health and social care services.

What gender do you identify yourself as?

Which age group are you in?

What is your religion?

What is your marital status?

What is your ethnicity?

What language(s) do you speak at home?

What is your sexual orientation?

Which area of the borough do you live in?

Which of these best descrbes your employment status

Are you a carer?

Prefer not to say No Yes

Do you consider yourself to have a long term condition or health and social care need?

Do you consider yourself to be disabled?

Prefer not to say No Yes

Only your overall rating, comment and name (if disclosed) will be visible online.

Eclipse Pharmacy