Group Consultations Patient Feedback Form

If you have attended a Group Consultation we would very much value your feedback.

Feedback should normally be provided after a couple of months after you attended the Group Consultation so that you can consider the impact it may have had on you.

Although we would like to be able to contact you after any feedback, the form can be submitted anonymously – in which case leave the personal details windows empty.

Group Consultations Patient Feedback Form

If you are human, leave this field blank.

Full Name:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Mobile Phone Number (preferable):

Home Phone Number:

Email Address:

If you don't provide an email address we won't be able to respond to you by email

Group Consultation Type attended *

Diabetes

Healthy Heart/Hypertension

Asthma

COPD

Depression/Mental Health

Date you attended Diabetes Consultation

Date you attended Healthy Heart Group Consultation

Date you attended Asthma Consultation

Date you attended COPD Consultation

Date you attended Depression/Mental Health Consultation

Do you feel more confident to manage your condition now, having been to a group consultation? *

1 (Not confident)

2

3

4 (Very confident)

Have you seen an improvement in your condition since attending the Group Consultation? *

1 (No improvement)

2

3

4 (Big improvement)

How much do you feel that a Group Consultation was more beneficial in treating your condition than a traditional 10 minute appointment? *

1 (Not beneficial)

2

3

4 (Very beneficial)

How likely are you to recommend Group Consultation to a member of your family or a friend? *

1 (Not recommend)

2

3

4 (Highly recommend)

Please add any additional remarks or suggestions about Group Consultations at the Practice.

*

I confirm that my enquiry is not urgent, and it may take up to 5 working days before I receive a reply

*

I confirm I am a registered patient at Montgomery House Surgery