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Referral feedback form
Dear colleague,

Thank you so much for providing feedback on the quality of my referral to you. I would be most grateful if you could take a moment to fill out this brief questionnaire.
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What is the reference number of the referral?
Including this will help to put your feedback into context (and confirm you're not a spammer!). Leave this blank if you would prefer anonymity.
How do you rate my referral in the following areas?
It may helpful to consider whether an improvement in the quality of the referral would have resulted in a better experience for the patient.
Poor
Fair
Average
Good
Excellent
Appropriateness
Sufficiency of information
Minimisation of unnecessary information
Clarity
Overall quality
Clear selection
Any other comments?
Developed by John Cosgrove (http://about.me/drjohncosgrove), provided under a Creative Commons 3.0 Unported license http://creativecommons.org/licenses/by/3.0/
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