Patient Feedback Form

Patient Feedback Questionnaire

Your opinion matters
A little bit about your visit...
Date of visit*

DíaMesAño
Reason for patient visit
Where did you hear about us
Impressions of the practice

Please base all answers on this visit only. Use a score between 1 and 5, being 1 poor and 5 excellent.

How useful was the information provided to you on how to find Pixie and Sera's practice?

	1	2	3	4	5

1 is Poor, 5 is Excellent

Convenience of appointment

	1	2	3	4	5

1 is Poor, 5 is Excellent

Were our explanations about your appointment clear and easy to understand?

	1	2	3	4	5

1 is Poor, 5 is Exellent

How well did we explain the reason for any delays (if any) to you?

	1	2	3	4	5

1 is Peor, 5 is Mejor

Were you treated with privacy, respect and dignity at all times?

	1	2	3	4	5

1 is Poor, 5 is Excellent

How well did we include you in decisions about your treatment?

	1	2	3	4	5

1 is Poor, 5 is Excellent

Following your appointment did we clearly explain what happens next?

	1	2	3	4	5

1 is Poor, 5 is Excellent

Please rate the information given on who to contact if you had concerns following you appointment

	1	2	3	4	5

1 is Poor, 5 is Excellent

During the Consultation

	1	2	3	4	5
Being polite
Feeling at ease
Listening
Assessing your condition
Explaining your condition and treatment
Decision about treatment
Providing treatment

If you received any medication to take home did we explain the potential side effects and what to do if you experience these?
Would you see this doctor again?
Would you recommend us to your friends and family?

Office Administration

	Poor 1	2	3	4	Excellent 5
Arrangements of referrals
Explanation of payment procedure
Method of communication
Courtesy of staff
Ease of making an appointment

Patient Feedback Questionnaire