PATIENT FEEDBACK FORM

Date *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

*

Compliment

Complaint

Suggestion

Other (detail below)

Optional: help us improve by rating the following:

(Please mark the box next to your chosen response)

The level of ease in booking your appointment is excellent.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

The waiting time for your treatment or appointment is great.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

The way you were included in making decisions about your treatment was what you wanted.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

The care or treatment you received from staff was of high standards.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

The way staff communicated with you was appropriate and respectful.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

The level of respect you received from staff needs to be improved.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree