Patient Survey Patient Survey Form Patient Survey By completing the short questionnaire you can help the Practice to improve its service. Please tick your response in the most appropriate box. The survey responses are collated annually in March. All responses are anonymous. Access to a Doctor or NurseSpeed at which the telephone was answered initially by Reception StaffPlease selectNo ExperiencePoorFairGoodVeryExcellentLength of time you had to wait for an appointmentPlease selectNo ExperiencePoorFairGoodVeryExcellentConvenience of day and time of your appointmentPlease selectNo ExperiencePoorFairGoodVeryExcellentLength of time waiting to check in with ReceptionPlease selectNo ExperiencePoorFairGoodVeryExcellentLength of time waiting to see the Doctor or NursePlease selectNo ExperiencePoorFairGoodVeryExcellentOpportunity of speaking to a Doctor or Nurse on the telephone when necessaryPlease selectNo ExperiencePoorFairGoodVeryExcellentOpportunity of obtaining a home visit when necessary (GP only)Please selectNo ExperiencePoorFairGoodVeryExcellentLevel of satisfaction with the GP Out of Hours servicePlease selectNo ExperiencePoorFairGoodVeryExcellentConsultation with GP or NurseMaking you feel at easePlease selectNo ExperiencePoorFairGoodVeryExcellentListening to your symptomsPlease selectNo ExperiencePoorFairGoodVeryExcellentInvolving you in decisions about your carePlease selectNo ExperiencePoorFairGoodVeryExcellentExplaining the problem and/or treatmentPlease selectNo ExperiencePoorFairGoodVeryExcellentShowing care and compassionPlease selectNo ExperiencePoorFairGoodVeryExcellentAllowing time to discuss your concernsPlease selectNo ExperiencePoorFairGoodVeryExcellentObtaining a repeat prescriptionPrescription ready on timePlease selectNo ExperiencePoorFairGoodVeryExcellentPrescription correctly issuedPlease selectNo ExperiencePoorFairGoodVeryExcellentHandling of any queriesPlease selectNo ExperiencePoorFairGoodVeryExcellentObtaining test resultsWere you told when to contact us for your results?Please selectNo ExperiencePoorFairGoodVeryExcellentResults available when you contacted usPlease selectNo ExperiencePoorFairGoodVeryExcellentAbout the staffThe information provided by the Reception and/or Admin staffPlease selectNo ExperiencePoorFairGoodVeryExcellentThe helpfulness of the Reception and/or Admin staffPlease selectNo ExperiencePoorFairGoodVeryExcellentAnd finallyCleanliness of the surgeryPlease selectNo ExperiencePoorFairGoodVeryExcellentDisabled facilities / accessPlease selectNo ExperiencePoorFairGoodVeryExcellentDo you feel like you are treated with dignity & respect at the practice?Please selectNo ExperiencePoorFairGoodVeryExcellentMy overall satisfaction with this PracticePlease selectNo ExperiencePoorFairGoodVeryExcellentAdditional InformationAny further comments OptionalThe below questions provide us with general information about the range of people who have responded to this survey. What age group are you? OptionalPlease Select0 – 17yrs18 – 25yrs26 – 40yrs41 – 64yrs65yrs+Are you Male or Female? OptionalPlease SelectMaleFemaleWhat ethnicity group are you? OptionalPlease SelectWhite/White BritishAsian/Asian BritishBlack/ Black BritishMixedChineseOtherPrefer not to sayPrivacy ProtectionInformation entered into survey forms is used only for the purposes of processing your survey information and is stored and accessed securely by designated staff. Issues raised in comments may be discussed between relevant members of staff. The information is used for quality monitoring purposes, in line with the expectations of those submitting the feedback. Any personal information transmitted via survey forms may be anonymised when this is required to ensure compliance with General Data Protection Regulation. This information is not shared with any external third party organisations. This information is retained for up to 28 days.Consent I consent to my information being used for the purposes described above and wish to submit this online form to The Cole House Surgery • 41 Park Road, Bedworth, Warwickshire, CV128LB.Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.