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* 1. Date to which your experience refers:

The date to which the feedback refers:

Date

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* 2. Name of client

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* 3. Name of patient

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* 4. Which of our disciplines did you refer to?

Cardiology

Dermatology

Internal Medicine

Neurology

Oncology

Ophthalmology

Orthopaedics

Soft Tissue Surgery

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* 5. From your recent referral experience of North Downs, how would you rate the following?
Please tick the following on a scale - 5 (excellent) to 1 (poor) (It is likely that some of the categories listed will not be relevant to your experience. If the question is not applicable, please tick N/A.)

	N/A	5 (excellent)	4	3	2	1 (poor)
Speed of telephone answering	Speed of telephone answering N/A	Speed of telephone answering 5 (excellent)	Speed of telephone answering 4	Speed of telephone answering 3	Speed of telephone answering 2	Speed of telephone answering 1 (poor)
Communication skills of our staff	Communication skills of our staff N/A	Communication skills of our staff 5 (excellent)	Communication skills of our staff 4	Communication skills of our staff 3	Communication skills of our staff 2	Communication skills of our staff 1 (poor)
Helpfulness of bookings co-ordinator	Helpfulness of bookings co-ordinator N/A	Helpfulness of bookings co-ordinator 5 (excellent)	Helpfulness of bookings co-ordinator 4	Helpfulness of bookings co-ordinator 3	Helpfulness of bookings co-ordinator 2	Helpfulness of bookings co-ordinator 1 (poor)
Efficiency of handling paperwork	Efficiency of handling paperwork N/A	Efficiency of handling paperwork 5 (excellent)	Efficiency of handling paperwork 4	Efficiency of handling paperwork 3	Efficiency of handling paperwork 2	Efficiency of handling paperwork 1 (poor)
Efficiency of handling emails	Efficiency of handling emails N/A	Efficiency of handling emails 5 (excellent)	Efficiency of handling emails 4	Efficiency of handling emails 3	Efficiency of handling emails 2	Efficiency of handling emails 1 (poor)
Speed of telephone response from clinician	Speed of telephone response from clinician N/A	Speed of telephone response from clinician 5 (excellent)	Speed of telephone response from clinician 4	Speed of telephone response from clinician 3	Speed of telephone response from clinician 2	Speed of telephone response from clinician 1 (poor)
Helpfulness of clinician(s)	Helpfulness of clinician(s) N/A	Helpfulness of clinician(s) 5 (excellent)	Helpfulness of clinician(s) 4	Helpfulness of clinician(s) 3	Helpfulness of clinician(s) 2	Helpfulness of clinician(s) 1 (poor)
Appointment availability	Appointment availability N/A	Appointment availability 5 (excellent)	Appointment availability 4	Appointment availability 3	Appointment availability 2	Appointment availability 1 (poor)
Overall quality of veterinary communication	Overall quality of veterinary communication N/A	Overall quality of veterinary communication 5 (excellent)	Overall quality of veterinary communication 4	Overall quality of veterinary communication 3	Overall quality of veterinary communication 2	Overall quality of veterinary communication 1 (poor)
Speed of referral letter provision	Speed of referral letter provision N/A	Speed of referral letter provision 5 (excellent)	Speed of referral letter provision 4	Speed of referral letter provision 3	Speed of referral letter provision 2	Speed of referral letter provision 1 (poor)
Management of the case	Management of the case N/A	Management of the case 5 (excellent)	Management of the case 4	Management of the case 3	Management of the case 2	Management of the case 1 (poor)
Feedback about North Downs from your client	Feedback about North Downs from your client N/A	Feedback about North Downs from your client 5 (excellent)	Feedback about North Downs from your client 4	Feedback about North Downs from your client 3	Feedback about North Downs from your client 2	Feedback about North Downs from your client 1 (poor)
Overall rating of your experience	Overall rating of your experience N/A	Overall rating of your experience 5 (excellent)	Overall rating of your experience 4	Overall rating of your experience 3	Overall rating of your experience 2	Overall rating of your experience 1 (poor)