Patient Feedback Questionnaire

Name*

Date of attending the practice*

Email Address*

Telephone number*

Optional: Name(s) of staff feedback relates to:

Was your appointment for NHS or private treatment?*

Tick the checkboxes: Tick the checkboxes: I consent for my feedback to be used on website and in-practice literature. (Unticked, your comments will not be made public). Feedback relates to Reception staff Feedback relates to Dentist, Therapist or Hygienist staff Feedback relates to Nursing staff Feedback relates to other I am a patient of Neem Dental Clinic and this feedback is based on my recent experience

How likely are you to recommend us to friends and family if they needed similar care or treatment? (Extremely Likely, Likely, Neither Likely or Unlikely, Unlikely, Extremely Unlikely, Don't know).*

Please tell us the main reason for the statement you have selected.*

18+ Age Confirmation 18+ Age Confirmation I confirm that I am 18 years of age or older and consent to Neem Dental Clinic securely storing and processing the personal information provided in this Patient Feedback Questionnaire for the purpose of evaluating and improving our services. Your feedback will be handled confidentially and in accordance with the UK Data Protection Act 2018 and other applicable privacy regulations. Where required by law or regulatory bodies, anonymised or relevant information may be shared with authorised organisations. You may withdraw your consent at any time, subject to any legal or regulatory obligations. Neem Dental Clinic reserves the right to disregard feedback that is abusive, malicious, or submitted inappropriately.

* Indicates required fields