Patient Feedback Form

Patient Feedback

We value your feedback to assist us to improve the service that we provide to our patients.

We ask for your help by completing this short survey relating to your recent treatment. We welcome your additional comments.

Which doctor is your feedback about? *

I was able to tell the doctor all the things that were important for me to tell them:

Strongly agreeAgreeUnsureDisagree

I am confident in the doctor's opinion of what is wrong with me:

Strongly agreeAgreeUnsureDisagree

I understand the plan given to me by the doctor:

Strongly agreeAgreeUnsureDisagree

I feel confident that the doctor has created an effective plan for me to deal with:

Strongly agreeAgreeUnsureDisagree

I believe i am able to carry out the plan given to me by the doctor:

Strongly agreeAgreeUnsureDisagree

At my initial consultation my views were listened to and my needs were met:

Strongly agreeAgreeUnsureDisagree

I was involved as much as I wanted to in making decisions about my treatment and care:

Strongly agreeAgreeUnsureDisagree

I was provided with adequate information, both verbally and written, about my treatment and care:

Strongly agreeAgreeUnsureDisagree

How would you describe the welcoming by the reception team?

ExcellentGoodAverageBelow Average

As far as I could tell, the staff involved in my care communicated with each other about my care and treatment:

Strongly agreeAgreeUnsureDisagree

I felt confident in the safety of my treatment and care:

Strongly agreeAgreeUnsureDisagree

Overall, the quality of care and treatment I received:

Exceeded my expectationsMet my expectationsWas below my expectations

Would you recommend Banyo Clinic to others? *

YesMaybeNo

If you selected Unsure, Disagree, Average or Below Average to any of the above, please provide further information

Overall, rate your satisfaction with this doctor, 1 = low, 10 = high

12345678910

Is there anything else you would like us to know?

If known, which receptionist served you today?

Name (Optional)

If you would like to be contacted about this feedback, please provide contact information.

Please wait, files are uploading..