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Friends and Family 

1.Thinking about your recent appointment, overall, how was your experience of our service?(Required.)
2.How was your experience of our booking process?(Required.)
3.How satisfied were you with the location of your appointment?(Required.)
4.How clear and easy was it to understand the information we provided about your appointment?(Required.)
5.How was your experience of the care/service you received at your appointment?(Required.)
6.How well do you feel you were treated with dignity and respect by our service?(Required.)
7.How would you rate the cleanliness of the clinic?(Required.)
8.Please could you explain why you gave those answers and anything else you would like to tell us?
9.If you would like us to respond to your comments please provide your surname and time of your appointment.
Organisations that provide healthcare for the NHS are required to collect information about the patients who use its services. The information on this form is collected to fulfil that obligation and to improve the services we provide. It is used for monitoring purposes only and ensures we treat all patients from across the community equally.

We will treat all personal information in line with current data protection legislation.

This form is entirely confidential. It is not traceable and does not affect the treatment you receive. Completion of the form is voluntary but please return it even if it is not complete.
10.What is your gender?
11.What is your age?
12.What is your ethnic group?
13.Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? (include any issues/problems related to old age)
14.Which clinic service-location did you visit? (e.g. Urology Glos - Hadwen Medical)(Required.)
15.Name of the Clinician at your appointment
16.Name of the Healthcare Assistant at your appointment
17.Date of your appointment
Date / Time
18.Survey submitted by(Required.)