Feedback questionnaire

Full Name 

Where do you live?

Please select your age group

Please select your gender

Have you had a fall previously?

Are you able to share details/cause of the previous fall?

Are there any other services that you would have been interested in seeing today?

Do you think your new slippers will help you?

If you are happy to be contacted regarding future events, services or feedback on the slippers, please leave your contact details below: 

Please enter date of form completion