Customer Questionnaire

Please complete our short on-line questionnaire, we would appreciate your thoughts and feedback.

Title

First Name *

Surname *

Email

Telephone

Address

Town

County

Post Code

Date of Birth (DD/MM/YYYY)

Do you get your appliances from
 Chemist Delivery Service

If you use a Delivery Service please state which

Which applies to you?
 Stoma Colostomy Ileostomy Urostomy Wound Care Spinal Cord Injury Continence

Please list which newspapers, medical magazines and publications you read:

How did you hear about Fittleworth?
 Healthcare Professional Advert Mailer Website Friend or Colleague Other

Would you recommend our service?
 Yes No Maybe

Finally, what can we do to improve the value of our website?

Please tick if you would like to be kept up-to-date with information from Fittleworth
 Yes No


Please leave this field empty.