Feedback Form

Feedback Questionnaire

This feedback form is provided for existing patients. Wellbeing & Health is committed to providing a quality service and we should be grateful if you would take the time to complete this form. Your comments will be used to help us improve our services and will form part of our annual Patient Survey. Any personal information you wish to provide will be treated in the strictest of confidence and will not be published.

*indicates required fields

Name:

*Are you an existing patient?:

Yes
No

If yes, when was your last appointment?:

*What was your appointment for?:

Consultation
Treatment

*What prompted you to use our services?:

Recommendation
Referral from another Practitioner
Internet
Local Advertising
Other Advertising

*Was it easy to obtain an appointment?:

Yes
No

If no, please give details:

Can we do anything to improve our service?:

Do you dislike anything about our service?:

*How would you rate our standard of care?:

Excellent
Good
Poor

*How would you rate quality of treatment?:

Excellent
Good
Poor

*How would you rate the attitude of staff?:

Excellent
Good
Poor

*How would you rate staff expertise?:

Excellent
Good
Poor

*How would you rate our premises?:

Excellent
Good
Poor

*How would you rate us overall:

Excellent
Good
Poor

Please click on the Submit button to send your feedback to us.

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513 Etruria road, Basford, Stoke on Trent, Staffordshire ST4 6HT
Telephone: 01782 619280
Email: admin@wellbeing-health.com