Patient Feedback Questionnaire

Please indicate how much you agree with each of the statements below:

1 = Totally disagree
2 = Partly disagree
3 = Neither agree nor disagree
4 = Partly agree
5 = Fully agree
N/A = Not appropriate

The information available to me (leaflets at reception etc) covers all that I need to know about using the practice’s services and looking after my dental care?

If you have any suggestions, please tell us what information or leaflets you’d find helpful.

I’m usually able to book appointments at times that suit me

When I have to pay for services, I believe the practice provides fair value for money

If you have any feedback about costs or value for money, please let us know.

It’s easy for me to enter and move around the building

If you have any suggestions, please let us know how we could improve access or movement around the building.

The reception, treatment room & other parts of the practice are always clean, comfortable & tidy

Whenever I want to talk about anything privately I am able to do so in a quiet area

If you have any suggestions, please let us know how we could improve.

I always feel well treated when I call to make an appointment or visit

I have confidence in the knowledge & abilities of the dentists, hygienists &others involved in providing my dental care

I’m always treated with dignity, gentleness and care by the dentist and others

My opinion is always taken into account when my treatment options are being discussed & agreed

My dentist’s name is:

James Gartshore

Colin Houston

On a scale of 1 to 10, where 1 means “not at all" and 10 means “definitely", please score how likely you would be to recommend our practice to another person:

Please briefly say why you chose this score:

Comments and suggestions:

Optional: If you would like us to respond personally to any issues you have raised, please provide your name and telephone number or e-mail address so that we can contact you.

Name

First Last

Email