Maternity and Gynaecology Patient Feedback Form

1 - How was the care you received?*: SelectExcellentGoodSatisfactoryPoorExtremely Poor

2 - Which service did you attend on your latest visit?*: SelectClinicCoil fittingColposcopyConsultant-led fetal scanningDay unit for routine and emergency diagnosticsDiabetes specialistsDiagnostic servicesDifficult smearEarly Pregnancy Assessment UnitEmergency gynaecology admissionsEPAUFertility and reproductive medicine (male and female)GynaecologyGynaecology Scanhealth checksIUD/IUS fittingManagement and treatment of polyps - fibroids and endometriosisMental health specialistsObstetric Medicine ClinicPessaries for prolapse fittingPhysiotherapyPre-pregnancyPre-term labour monitoringProlapse repairRapid accessRecurrent miscarriageSpecialist dermatologySpecialist high BMI pathwayUrogynaecology

3 - Did you receive any relevant information relating to your appointment in a timely manner?*: SelectYesNoInformation not received

4 - Do you wish to raise any concerns regarding your care?*: SelectYes (If Yes please complete section 5 below)No

5 - Are there any improvements you think we could make?:

6 - On a scale of 1 to 10, where 1=Poor and 10=Exceptional, how happy were you with the service we provided?*: 12345678910

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