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Patient Satisfaction Survey
Please enable JavaScript in your browser to complete this form.
Please tick one answer for each question and submit your feedback to our clinic administration. Dear Patient, we would be grateful if you would complete this questionnaire about your visit to the doctor today. Your feedback from this survey will enable us to identify areas that may need improvement. Your opinions are therefore very valuable. Please answer all the questions below. There are no right or wrong answers and your doctor will not be able to identify your responses. Thank You
Date and time of your appointment
Date
Time
Name of your Doctor / Clinician
*
Select the Doctor who who attended to you
Dr A
Dr B
Dr C
Did this doctor make you feel relaxed and welcome?
*
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Do you feel this doctor listened to you?
*
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Did the doctor explain things to you in a way you could understand?
*
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Were you involved as much as you wanted to be in decisions about your care and treatment?
*
Not Applicable
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Do you have confidence in the decisions made about your condition or treatment?
*
Not Applicable
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Do you know what will happen next with your care?
*
Not Applicable
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Do you know what to do if your condition gets worse?
*
Not Applicable
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Did the doctor treat you with respect and dignity?
*
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Do you trust this doctor?
*
No, not at all
No, not really
Yes, but not fully
Yes
Yes, completely
Comments
Do you have any specific comments about this doctor from this consultation?
Submit