HH Collaborative PCN Patient Feedback Form

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Please do not use any personal information on the form. If you would like to contact us to discuss a matter further please use the contact us form via our website at www.hhcollaborative.co.uk

1. Date of appointment? *

YYYY

2. Please select the service you attended *

Ear Microsuction Service

Dietitian

First Contact Physio

Health and Well-being Coach

MSK Ultrasound Service

Paramedic

Pharmacy First Clinic

Podiatry Clinic

Same Day Access Clinic

Social Prescriber Link Worker

Spirometry Service

Other:

3. Where did you attend your appointment *

Cedar Brook

Glendale

Hayes

Hesa

Kincora

North Hyde

The Warren

Townfield

4. How did you find the experience of receiving an appointment? *

a) Very easy

b) Easy

c) Somewhat easy

d) Difficult

e) Somewhat difficult

f) Very difficult

5. Were our staff empathetic to your needs? *

a) Very empathetic

b) Empathetic

c) Somewhat empathetic

d) Not empathetic

6. How long did you have to wait until the clinician attended to you? *

a) As I expected

b) Had to wait more than I expected

7. Were you satisfied with the clinician you were allocated with *

a) Somewhat satisfied

b) Satisfied

c) Somewhat dissatisfied

d) Dissatisfied

e) Very dissatisfied

8. How happy are you with the clinician’s treatment?

a) Happy

b) Somewhat happy

c) Okay

d) Dissatisfied

Clear selection

9. How easy was it to understand the advice or treatment plan given to you? *

a) Very Easy

b) Fairly easy

c) Difficult

d) I didn't receive a plan

10. Were we able to answer all your questions?

a) Yes

b) Somewhat yes

c) Some questions left unanswered

d) No

Clear selection

11. How likely are you to recommend us to your friends and family?

a) Very likely

b) Likely

c) Somewhat likely

d) Not very likely

e) Never

Clear selection

12. Overall, how would you rate the service? (5 being the highest rating)

Clear selection

13. Is there any thing that you feel we should improve upon?

Submit

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