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Virtual Clinic

Clinic

Type of clinic

Time of appointment

24hr clock example 13.20 (1.20 pm)

Date of appointment

Example 13/03/20 (13 March 2020)

Was your appointment on time?

No it was early

Yes it was on time

No it was late

How early or late was the appointment?

5-10 minutes

10-15 minutes

15-20 minutes

20-30 minutes

30 minutes +

Did the caller check you demographic information?

Example = . DOB/Address/Ethnicity

Yes

Did you understand the consultation and do you know the next steps?

Yes

What did you not understand?

what was good?

what could be improved?

out of 5 starts how would you rate the expericne?

1 = worst - 5 = Best

First name *

Last name *

Leave feedback anonymously?

Email address

Telephone number

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