Patient Feedback Form

Patient Feedback Form

Your details (you may choose to keep your details confidential)
Name*

First NameLast Name
Email*
example@example.com
Date of appointment*

DayMonthYear
Why homeopathy?*
Please tell us what prompted you to visit a homeopath.
About your appointment *
Which clinic did you attend and who was your homeopath?
Please highlight (or circle) each line in each table below indicating your opinion on the level of performance.

Appointment...*

	Very poor	Poor	Adequate	Good	Excellent
How easy was it to make an appointment?
Did your appointment take place on time?

Consultation…*

	Very poor	Poor	Adequate	Good	Excellent
Did the remote communication method, i.e. Zoom call, telephone call work for you?

Homeopath…Ms Hamilton*

	Very poor	Poor	Adequate	Good	Excellent
Was polite, friendly and professional
Listened to me and let me ask questions
Checked that I was happy with planned treatments

Would you recommend the clinic to a friend? (Please tick a circle)*

YesNoUndecided
Is there anything you would like to say about your homeopath and the clinic?*
About your feedback
May we use your testimonial in educational and marketing materials? (highlight or tick one from the list below) *

Yes, and it is ok to use my name after the testimonialYes, but please keep my name confidential and just use my initialsYes, but please keep my name and initials confidentialNo
Would you be happy to tell your story to our Communications Manager? (highlight or tick one from the list below)*

Yes, I would be happy for my story to appear in the HUK’s popular magazine HEALTH AND HOMEOPATHY (please don’t forget to include your telephone no. in the textbox below)No, I do not want to tell my story
Phone Number*
Thank you for your feedback.

Please press the submit button below to submit this form.
Homeopathy Clinic

The clinic currently offers patient consultations two times per month. Although treatment is provided at a charitable rate, patients are encouraged to make donations with the aim of helping the clinic to become self-funding in the longer term. H.UK hopes that local support will grow to help ensure the homeopathy clinic serves the people of Dumfries and Galloway for many years to come.

Homeopathy UK welcomes donations through a number of channels, please see overleaf for details.
How to Donate

There are three ways you can donate directly to the clinic. Every penny donated counts towards keeping the clinic running and helps provide access to medical homeopathy in the Dumfries and Galloway area. We would like to acknowledge receipt and thank you for your donation; please complete your details below.

By cheque/online

Pop your cheque and this postcard into the direct giving envelope and post it to us. Please make your cheque payable to the Homeopathy UK. Or go online https://www.homeopathy-uk.org

By bank transfer

Bank Name: HSBC Plc | Account number: 21084933 | Sort Code: 40-04-25 | Reference: Clinic location plus name or initials

Complete the details below (including the tick box), pop this postcard into the direct giving envelope and post it to us.
PLEASE ENTER YOUR DETAILS IN BLOCK CAPITALS

I have donated by cheque (tick)I have donated by bank transfer (tick)
Amount donated (tick):

£75£50£35Other £ (please specify)
Email
example@example.com
Name

TitleFirst NameLast Name
Home Address

Street Address

Street Address Line 2

CityCounty

Postal Code
Telephone
Date

MonthDayYear
Appointments | 0203 640 5903 | admin@homeopathy-uk.org
Dumfries and Galloway Homeopathy is a charitable clinic run by Homeopathy UK in partnership with SHRET; we are a registered charity (number 235900) Registered Charity No: SCO49515 – Scotland.| https://homeopathy-uk.org | 020 3640 5903
Should be Empty:

Patient Feedback Form

About your feedback