North Kent Community Ophthalmology Service – Patient satisfaction questionnaire

We’d like you to feedback to us about the level of service being provided so it can continually be improved to feedback to us please complete the short survey below.

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* 1. Please enter the time and date of your appointment below

Appointment date and time

Date

Time

AM/PM

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* 2. What clinic location were you seen in?

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* 3. Please rate the following statements
1 (poor), 2 (unsatisfactory), 3 (average), 4 (good), 5 (very good)

	1	2	3	4	5
The ease of booking an appointment	The ease of booking an appointment 1	The ease of booking an appointment 2	The ease of booking an appointment 3	The ease of booking an appointment 4	The ease of booking an appointment 5
The waiting time for an appointment The North Kent Ophthalmology Service is easy to contact	The waiting time for an appointment The North Kent Ophthalmology Service is easy to contact 1	The waiting time for an appointment The North Kent Ophthalmology Service is easy to contact 2	The waiting time for an appointment The North Kent Ophthalmology Service is easy to contact 3	The waiting time for an appointment The North Kent Ophthalmology Service is easy to contact 4	The waiting time for an appointment The North Kent Ophthalmology Service is easy to contact 5
The clinic location	The clinic location 1	The clinic location 2	The clinic location 3	The clinic location 4	The clinic location 5
Access to the clinic (parking, disabled access etc)	Access to the clinic (parking, disabled access etc) 1	Access to the clinic (parking, disabled access etc) 2	Access to the clinic (parking, disabled access etc) 3	Access to the clinic (parking, disabled access etc) 4	Access to the clinic (parking, disabled access etc) 5
The attitude of the optometrist	The attitude of the optometrist 1	The attitude of the optometrist 2	The attitude of the optometrist 3	The attitude of the optometrist 4	The attitude of the optometrist 5
How well the optometrist listened to you	How well the optometrist listened to you 1	How well the optometrist listened to you 2	How well the optometrist listened to you 3	How well the optometrist listened to you 4	How well the optometrist listened to you 5
The explanation of your treatment	The explanation of your treatment 1	The explanation of your treatment 2	The explanation of your treatment 3	The explanation of your treatment 4	The explanation of your treatment 5
The quality of the literature you received regarding your condition	The quality of the literature you received regarding your condition 1	The quality of the literature you received regarding your condition 2	The quality of the literature you received regarding your condition 3	The quality of the literature you received regarding your condition 4	The quality of the literature you received regarding your condition 5
Overall consultation satisfaction	Overall consultation satisfaction 1	Overall consultation satisfaction 2	Overall consultation satisfaction 3	Overall consultation satisfaction 4	Overall consultation satisfaction 5

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* 4. How likely are you to recommend the service to friends and family?

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* 5. If you would like to make any other comments about the service you have received, please leave them here.

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* 6. Should you wish to be contacted directly regarding you feedback, please leave your name, number and email address here:

Name

Number

Email address