Patient Feedback Form on your local NHS Services (not your GP services)

As part of the West London Clinical Commissioning GroupĀ  commitment to improving your local NHS services, we would value your feedback as a patient. Please fill out this form.

Which service do you want to tell us about and where you received treatment?

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* 1. Which service do you want to tell us about and where you received treatment?

Which hospital?

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* 2. Which hospital?

When did this happen?

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* 3. When did this happen?

On a scale of 1 (very poor) to 5 (very good), how would you rate the following?

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* 4. On a scale of 1 (very poor) to 5 (very good), how would you rate the following?

  1 (very poor) 2 3 4 5 (very good) N/A
Accessing the service e.g. arranging/cancelling appointments
Waiting time for an appointment
Waiting time at the clinic/service
Overall helpfulness of staff
Information on your illness/treatment
Were staff aware of your medical history
Overall cleanliness of the environment
Meeting the needs of carers and families
How would you rate your overall experience
If you could recommend one thing that would improve the service you received, what would it be?

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* 5. If you could recommend one thing that would improve the service you received, what would it be?

A bit about you. We ask for these details to ensure your feedback is as representative as possible. This section is voluntary, please be assured that all information will be treated with the strictest of
confidence and will remain anonymous

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* 6. A bit about you. We ask for these details to ensure your feedback is as representative as possible. This section is voluntary, please be assured that all information will be treated with the strictest of
confidence and will remain anonymous

If you would like to discuss your feedback in more detail enter your details

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* 7. If you would like to discuss your feedback in more detail enter your details

Thank you for completing this feedback form. Your comments are very important to us. If you wish to make a complaint about the service, please contact the complaints officer on 020 3350 4567 or by email atcwhh.complaints@nhs.net

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