MINOR SURGERY PATIENT FEEDBACK FORM APRIL 2023- MARCH 2024

We would be grateful if you would complete this feedback form following your recent minor surgery.

We aim to deliver complete patient satisfaction. Collecting and acting on our patient feedback is vital to our achieving this. Your opinions are therefore very valuable.

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* 1. How likely are you to recommend our clinic to friends or family if they needed similar care or treatment? Please Select one of the following options:

Extremely likely

Likely

Neither likely nor unlikely

Unlikely

Extremely unlikely

Don't know

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* 2. Were you treated with courtesy throughout your appointment(s) by administration staff and the health professionals?

Yes

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* 3. Were you given clear explanation of your condition, any medication requirements, and your treatment?

Yes

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* 4. Were you involved as much as you wanted to be in decisions about your care and treatment?

Yes

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* 5. How did you find the injection of local anaesthetic?

Not too bad

Uncomfortable

Painful

Very painful

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* 6. How effective was the local anaesthetic in preventing pain during the operation? On a scale of 1-10 with 1 being not at all & 10 being completely.

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* 7. Did you feel you had enough time to ask questions or raise any concerns?

Yes

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* 8. Was the explanation given by the health professional clear and easy to understand?

Yes

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* 9. How much information about your condition or treatment was given to you?

Not enough

The right amount

Too much

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* 10. Did you have any of the following complications? (please select appropriately)

Infection requiring antibiotics

Excessive bleeding post-surgery

Any other complications? Please list below:

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* 11. Are you happy with the outcome of the surgery?

Yes

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* 12. Procedure date:

Date

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* 13. Name of doctor

Dr M White

Mr G Putnam

Dr C Chou

Dr D Brigham

Deborah Bradley

Other (please specify)

MINOR SURGERY PATIENT FEEDBACK FORM APRIL 2023- MARCH 2024

Question Title

* 1. How likely are you to recommend our clinic to friends or family if they needed similar care or treatment? Please Select one of the following options:

Question Title

* 2. Were you treated with courtesy throughout your appointment(s) by administration staff and the health professionals?

Question Title

* 3. Were you given clear explanation of your condition, any medication requirements, and your treatment?

Question Title

* 4. Were you involved as much as you wanted to be in decisions about your care and treatment?

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* 5. How did you find the injection of local anaesthetic?

Question Title

* 6. How effective was the local anaesthetic in preventing pain during the operation? On a scale of 1-10 with 1 being not at all & 10 being completely.

Question Title

* 7. Did you feel you had enough time to ask questions or raise any concerns?

Question Title

* 8. Was the explanation given by the health professional clear and easy to understand?

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* 9. How much information about your condition or treatment was given to you?

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* 10. Did you have any of the following complications? (please select appropriately)

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* 11. Are you happy with the outcome of the surgery?

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* 12. Procedure date:

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* 13. Name of doctor

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* 14. Finally, we would be grateful for any of your own comments regarding the treatment you received, the service as a whole or any part of it.