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Your name

Your email (please provide a work email address)

Name of organisation

Name of care home

Job role

Do you have any specific dietary requirements or allergies?
YesNo
If yes, please specify dietary requirements or allergies

Do you have any feedback you can offer about your experience of using DOC@HOME? (optional)

If you have offered feedback, do you consent to us using this for training and/ or marketing purposes?
No feedback givenYes, use my feedback and my nameYes, use my feedback but don't include my nameNo, only use my feedback if myself and the organisation remain anonymous

Which appears first in the alphabet, B or K?

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I accept these terms (required)