VMS Patient Satisfaction Survey v2

1
Date
Date
Day
Month
Year
21
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Hour
48
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
2
If you know the name of your medic please let us know who it was.
Huge
Large
Normal
Small
Ok
Ok
3
Who are you filling this questionnaire for?* This field is required.
Yourself
Your child
Child in you care
Your spouse or partner
Another relative
A friend
4
We were involved and informed in the planning of our care, and in a way that we could understand.* This field is required.
Agree
Disagree
Not applicable
5
My family/carer were involved and informed in the planning my care (with my consent), and in a way that they could understand.* This field is required.
Agree
Disagree
Not applicable
6
We were treated with dignity and respect throughout the treatment.* This field is required.
Agree
Disagree
Not applicable
7
We were given enough privacy when treated or advised.* This field is required.
Agree
Disagree
Not applicable
8
We were seen in a clean and safe environment.* This field is required.
Agree
Disagree
Not applicable
9
We had confidence and trust in the medical staff who was treating / advising us.* This field is required.
Agree
Disagree
Not applicable
10
Our personal information was treated confidentially.* This field is required.
Agree
Disagree
Not applicable
11
The treatment (or advice / support) that we received was effective.* This field is required.
Agree
Disagree
Not applicable
12
I would recommend the service to my family and friends.* This field is required.
Agree
Disagree
Not applicable
13
Overall my feedback is...* This field is required.
Positive
Neutral
Negative
14
Please add any other comments or suggestions that you would like to make below.
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Large
Normal
Small
Ok
Ok
15
If you are happy for a member of our management team to contact you about your responses, please enter your contact details over the next three pages.
16
NameOptional
First Name
Last Name
17
EmailOptional
example@example.com
18
Phone NumberOptional
Area Code
Phone Number
19
Vie Medic Services Ltd will hold your information securely in accordance with the General Data Protection Regulation. We may share information you provide with official organisations such as the Care Quality Commission as part of our ongoing commitment to improving the quality of the services we deliver.
Please tick here if you are happy for us to use your feedback in this way.
Please tick here if you are happy for your feedback to be used anonymously on service information leaflets and web pages.
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