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* 1. About You

  Under 18 19-34 35-54 55-74 75+
Female
Male

2. On what basis was payment made for your visit?

3. If you are insured, which insurance company are you insured by?

* 4. What influenced you to choose The London Orthopaedic Clinic

* 5. Would you recommend The London Orthopaedic Clinic to friends and family?

6. First Impressions?

  Very Good Good Fair Poor
Efficiency of appointment booking
Information given prior to arrival
convenience of appointment
Overall impression

7. On Arrival

  Very Good Good Fair Poor
Directions to appropriate floor
Greetings on arrival
Waiting room comfort
Promptness of attention
Overall impression

8. Availability of Amenities

  Very Good Good Fair Poor
Quality of refreshments
Papers/magazines
Disabled facilities
Conditions of restrooms/waiting area
Overall impressions

9. Consultant Care - Speed in which you were seen

* 10. Which Consultant did you see?

11. Consultant Care

  Very Good Good Fair Poor
Explanation of presenting condition and treatment options
Level of privacy when undressing
Overall consultant care

12. Nursing care - speed in which you were seen

13. Nursing Care

  Very Good Good Fair Poor
Explanation of procedure
Explanation of aftercare
Time & attention given
Cleanliness
Overall nursing care

14. Radiology - Speed in which you were seen

15. Radiology

  Very Good Good Fair Poor
Explanation of procedure
Time & attention given
Cleanliness
Courtesy of staff
Overall Care

16. Financial administration

  Very Good Good Fair Poor
Assistance with financial queries
Ease of financial arrangements

17. Comments & Suggestions

18. If you would like to be contacted about any of these points please include your name and address below.

* 19. Please let us know if you are happy for your comments to be used on our website ( N.B No names or details will be mentioned)

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