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The UK’s integrative cancer care charityHelpline 0870 163 2990
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Information About You

* Your Name
* Your Email
Your Role
* What is the cancer type you have (or the patient has)?
Please select the location of the patient (UK county)
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Step 1

Information about the Clinician and the Treatment

* Clinician's Name
Clinician's Role
If you know the the name of the clinic or hospital that you saw the clinician at - please supply it below.
* The approximate date of your most recent previous interaction with the clinician (Displays as: mm--dd-yyyy format).
* The approximate total number of interactions (e.g., in-person appointment, video call, etc.) you had with the clinician
* What treatment(s) did you (or the patient) have?
If you are have had more than one treatment or your treament is not listed, you can select "More than One" or "Other" from the dropdown menu below. If you are “Not Sure” then select that option.
Where did you see them - NHS or Private?
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Step 2

Share Optional Information

* Would you like to share additional information (i.e. overall rating, comments, and badges for particular qualities of support) about your experience with the clinician?
How would you rate your OVERALL experience with the clinician?
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Step 3

Your Review

Please provide a short phrase summarising your experience with the clinician. This phrase will be used as the title or heading of your individual comment (minimum 5 characters).
What are there specific details from your experience with the clinician that you would like others to know about? (minimum 30 characters).

Characters remaining: 1000

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Step 4

Rate the Clinician

Which of the following adjectives would you use to describe your clinician? Pick one - or as many as you’d like to - and assign an appropriate number of trophies.
Attentive
You felt that while you were with them, their attention was focused on you and your situation, and they were not unduly distracted by other matters.
Empathic
You sensed that they had genuine concern for you and your situation and wanted to do all they could to help.
Open-minded
You found they were willing to embrace the idea that other approaches besides the treatment offered by the hospital could contribute significantly to your wellbeing.
Respectful
You felt addressed as an equal at all times and always allowed the space to make your own decisions about your treatment options.
Responsive
Despite the routine nature of their work with critically ill people, they were able to maintain an awareness of the fact that your life is in the balance and respond with appropriate urgency and care.
Supportive
You sensed that they really wanted the best for you, and received a positive response from them to any suggestions for additional ways to improve your wellbeing and outlook.
Well-informed
You felt you were dealing with an expert in their field with extensive experience, and possibly also that they were aware of other developments in cancer treatment outside their own speciality.
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Step 5

Please Confirm Your Consent

By submitting this form, I confirm that I have had direct interactions with the clinician who I am recognising through this form, and all information is true and correct to the best of my knowledge.
* Under GDPR regulations we will hold details of all enquiries, if you wish the data to be deleted please get in touch.
You agree to the above retention of your data.
You will be sent a copy of your submission by email.

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