Feedback Form

Feedback Form

Thank you for using our service. Please share your feedback by filling in the information below.

Your name *

Do you agree to be contacted regarding this matter?

Yes

No

Your telephone number (optional)

Email Address (optional)

I confirm that I am a registered patient with Corfton Road Surgery *

Please rate the following aspects of our practice. *

	Very Good	Good	Neutral	Bad	Very Bad
Ease of getting appointments	Very Good	Good	Neutral	Bad	Very Bad
Ease of getting an appointment with your preferred doctor	Very Good	Good	Neutral	Bad	Very Bad
Ease of getting an appointment with the nurse	Very Good	Good	Neutral	Bad	Very Bad
Ease of getting through to the surgery on the phone	Very Good	Good	Neutral	Bad	Very Bad
Satisfaction with the way the doctor handled your consultation	Very Good	Good	Neutral	Bad	Very Bad
Satisfaction with the way the nurse handled your consultation	Very Good	Good	Neutral	Bad	Very Bad
Overall satisfaction with the surgery	Very Good	Good	Neutral	Bad	Very Bad

What do you most like about our practice?

What do you least like about our practice?

Other comments

Overall, how satisfied are you with our practice? *

How likely are you to continue to use our practice? *

Would you recommend this practice to others? *

Yes

No

Enter the word in the image *
captcha