MINOR SURGERY PATIENT FEEDBACK FORM APRIL 2022- MARCH 2023

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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. 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.

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* 13. Procedure date:

Date

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* 14. Name of doctor

Dr M White

Mr G Putnam

Dr C Chou

Dr D Brigham

Deborah Bradley

Other (please specify)