Patient Feedback Form

We really value patient feedback at Chalk Stream Medical. Patient feedback enables us to monitor the quality of our service and also enables us to make changes and improve our service where necessary. Our survey below will only take 2-3 minutes of your time and we would be most grateful for your response.

    Providing us your contact details allows us to discuss any feedback with you, where necessary. This is optional:

    Would you be happy for this feedback to be posted anonymously on our website or in other publicity? The information would be anonymised with just your initials and nearest town displayed.

    Type of Consultation:

    Name of Doctor:

    Please tell us how you feel about the following statements:

    I was able to book an appointment within a good timeframe:

    Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
    I felt the consultation was thorough and unhurried:

    Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
    My Doctor made me feel welcome and relaxed:

    Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
    My Doctor involved me in decisions during my consultation:

    Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
    I felt confident that my Doctor had good clinical knowledge:

    Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
    I am clear about what will happen next:

    Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
    I know what to do if my condition gets worse:

    Strongly AgreeAgreeNeutralDisagreeStrongly Disagree
    I would recommend Chalk Stream Medical to my family and friends:

    Strongly AgreeAgreeNeutralDisagreeStrongly Disagree

    If you have any other comments, we would love to hear your thoughts:



    Finally, please tell us how you heard about us: