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Hertfordshire County Council

Purple Star Feedback Form


Purple Star logo             NHS logo

Lady pointing her finger
The Purple Star Team need your help!
Purple Star logo We want to know how good your doctors surgery is at looking after people with learning disabilities.
Man asking a question We need to hear what people with learning disabilities and carers think about their doctors.
You and anyone who helps you can help us by filling in this form.
Lady on the telephone If you would prefer to, you can call us on
01438 84 46 81.

Man being asked his name What is your name? (optional)

Please write your answer below. 


Picture of a mobile phone What is your telephone number? (optional)

Please write your answer below. 


3. If you are someone who supports this person, what is your name and contact details? (Optional)


GP Surgery image What is the name and place of your doctors surgery?


Purple Star logo with question mark beside it Do you think your doctors have a Purple Star?


Man giving thumbs up Have your doctors invited you for your annual health check?


Man giving thumbs up Did your doctor send you an annual health check preparation form when they invited you for your annual health check?



Man giving thumbs up Has your doctor sent you a Communication and Reasonable Adjustment form to fill in?


Man giving thumbs up At your appointments, does the nurse or doctor ask you if you have a purple folder?


Man giving thumbs up Were you given a Stay Healthy at Home Checklist by your doctor?


Man giving thumbs up Can you tell us what you think your doctors surgery does well?


Lady giving thumbs down Can you tell us what you think your doctors surgery could do better?

Website displayed on a laptop To find out more about the Purple Star and your health go to our website www.hertfordshire.gov.uk/LDmyhealth
Laptop shwing a lock image on screen We will store this form safely on our computer.
Group of people having a meeting We will share your thoughts and ideas at our Purple Star Meetings.
We may also share this with the health service to help them improve.
Picture of a red cross We will not share your name or telephone number without speaking to you first.