Information enquiry form Please use this form to ask your question about NHS or social care services in Coventry or if you would like information about how to raise a concern or complaint. The Healthwatch Information line is a confidential service and is entirely independent of NHS and social care services. Please fill out as many of the questions below as you can to help us give you the information you need 1a. Your first name 1b. Your last name 2. Your telephone number 3. Your email address 4. Please tell us where you live Coventry Warwickshire Solihull Birmingham Other Other… Enter other… 5. Your home address 6a. Service type - Select -GP servicesDentistPharmaciesHospital inpatient (day treatment or overnight)Hospital outpatients' appointmentsMental health supportSocial care eg care homes, and home careAccident and emergency/minor injury unitsAmbulances and paramedicsNHS 111Other issue/service (if other, please tell us which issue/service you are referring to) 6b. If other, please tell us with service type 7. Name of service Please give the name of the hospital, GP practice or other service as this will help us with your enquiry 8. Your question or enquiry 9. How did you hear about Healthwatch Coventry? - Select -Another organisation's websiteFriend, family or neighbourHealth or social care professionalHealthwatch EnglandHealthwatch stall or eventInternet SearchLeaflet or posterLocal councillor or MPMedia: newspaper, radioNHS PALS organisationOther Previous UserSocial MediaVoluntary organisation We collect information about the people who contact us so that we can check that we reach different communities, genders and age groups 10. You age - None -Under 1213-15 years16-17 years18-24 years25-49 years50-64 years65-79 yearsOver 80 yearsPrefer not to say 11. Your ethnicity - None -ArabAsian/Asian British: BangladeshiAsian/Asian British: ChineseAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: Any other Asian/Asian British backgroundBlack/Black British: AfricanBlack/Black British: CaribbeanBlack/Black British: Any other Black/Black BritishMixed/multiple ethnic groups: Any Mixed/multiple ethnic groupsWhite: British/English/Welsh/Scottish/Northern IrishWhite: IrishWhite: Eastern EuropeanWhite Gypsy, Traveller or Irish TravellerWhite; RomaWhite: Any other white backgroundAny other Ethnic groupPrefer not to say 12a. Your gender - None -FemaleMaleNon binaryPrefer not to sayPrefer to self describe 12b. Is your gender identity the same sex as assigned at birth? - None -YesNoPrefer not to say 13a. Do you consider yourself to be disabled? - None -NoYesPrefer not to say 13b. Please give details about your disability - None -Physical or mobility impairmentSensory impairmentLearning disabilityMental health conditionLong term health conditionOther Prefer not to say 14. Are you a family or unpaid carer? - None -YesNo Prefer not to say Tell your story Sometimes it helps to highlight what needs to change through a more detailed case study – can we contact you to discuss whether your story could be a case study? We can talk though what this will involve. 15. I am happy to be contacted by Healthwatch Coventry to discuss whether my story could be a case study used to highlight issues to local health and care managers and work for change - Select -YesNo Consent and Permission In order to provide you with information we record your personal contact details and information about your query. This also helps us if you return to us with any more questions and to check what people think of our service. We do not sell your information. We will only pass on your information to external organisations that could help you if you give us specific consent. We keep logs of issues raised with Healthwatch Coventry. When we do this we will not include your name, address or any other personal details and we take steps to make sure any examples of experiences of services we use are not identifiable. 16. Please confirm you are happy for us to use your information in this way? - Select -Yes Submit Leave this field blank
