Totally Patient Feedback Survey

We would like to ask you about your recent experience of our services.

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Did you receive a text message directing you to this form?

Yes

No - I scanned a QR code, visited the Totally website, or accessed this form some other way

What is your age? (Please indicate the age of the patient if completing on their behalf)

What is your ethnic origin? (Please indicate the ethnic origin of the patient if completing on their behalf)

Comments:

This is required

What is your sex and gender identity? (Please indicate the sex and gender identity of the patient if completing on their behalf)

Comments:

This is required

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Which of our services did you visit?

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What was the date of your visit?

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What was the time of your visit/appointment?

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Overall how was your experience of our service?

Very Good

Good

Neither Good nor Poor

Poor

Very Poor

Don't Know

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How likely are you to recommend our service to friends or family?

Very Likely

Likely

Neither Likely nor Unlikely

Unlikely

Very Unlikely

Don't Know

Please explain your rating of our service.

Please tell us about anything that we could have done better.

If you visited an Urgent Treatment Centre, did you check-in using an eKiosk?

Yes

No - I checked-in at the reception desk

Don't know

We'd love to hear more about your experience with us. If you're happy for us to contact you with some follow-up questions, please leave your email address or telephone number below.

Email address:

Telephone:

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