Patient Feedback Form - Ears & Hearing UK

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Date*

Are you filling in this questionnaire for:*

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(Optional and Confidential)

First Last

How good was Mr Pringle at each of the following:*

	Excellent	Good	Satisfactory	Less Than Satisfactory	Poor	Does Not Apply
Being polite
Making you feel at ease
Listening to you
Assessing your medical condition
Explaining your condition and treatment
Answering your questions
Involving you in decisions about your treatment
Providing or arranging treatment for you
Giving you sufficient time

Please decide how strongly you agree with the following:*

I am confident about Mr Pringle's ability to provide care*

Yes
No

I would be completely happy to see Mr Pringle again*

Yes
No

I would be happy to recommend Mr Pringle to friends or family*

Yes
No

Do you have any comments or suggestions as to how Mr Pringle could improve the care he provides?

Potential patients greatly value reading testimonials about the doctor who they are going to see. Mr Pringle would be extremely grateful if you could provide a short Testimonial about your consultation / operation with him.

Are you willing for Mr Pringle to use your Testimonial on his website?

Yes
No

	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
Mr Pringle will keep information about me confidential
Mr Pringle is honest and trustworthy

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