Patient Feedback Questionnaire
Greetings. A warm welcome to you from Dr Tina Khanam here. Do you want clearer vision?Perhaps you are weary of glasses, uncomfortable in contact lens or simply intrigued by laser and surgical solutions? Rest assured, I’m here to provide clarity and guidance. Feel free to schedule an appointment with me by completing the form below. Your vision matters, and I’m here to assist you every step of the way. Thank you for considering my services.
Dear Patient
Thank you for agreeing to provide feedback on the way you have been treated by
DOCTOR | TINA KHANAM |
GMC No. | 6130123 |
Feedback from patients can help doctorsto continue to improve standards of patient care.
Your feedback is anonymous and will be collated with that from other patients to form a report for the doctor to review
during their appraisal.
If you are filling in thisin forsomeone else, please answer the following questions from the patient’s point of view.
How to complete this questionnaire
• Use the rating scale (overleaf) to assess to what extent the doctor displayed the behaviour described.
• Please rate each item by circling the number that best represents your opinion as shown in this example:
1. making you feel at ease?
• If you have had no opportunity to observe this behaviour, please circle c/c (can’t comment/don’t know)
• Try to use the full range ofscores to make the strengths and weaker areasstand out
• At the end of the questionnaire you have the opportunity to add brief comments about the doctor. This will help the doctor to understand the ratings that you have given and how to improve the care provided. Edgecumbe does not endorse abusive language and any feedback containing offensive comments will be disregarded
If you have any serious concerns, about this doctor or any aspect of the care you receive, please contact the organisation directly and ask for their PAL’s liaison. They will log and handle your concern with discretion.
Practice Office
24, Fitzroy House, Lynwood Dr, Worcester Park KT4 7AT
Time: Monday-Friday 08.30-16.30 Tel:+44 7824 481120
Enquiries to: info@tinakhanam.com
Website:https://tinakhanam.com/
RATING SCALE
1 | Not effective/ poor |
2 | Partially effective/lessthan satisfactory |
3 | Mostly effective/ satisfactory |
4 | Effective/ good |
5 | Very effective/ very good |
6 | Extremely effective/ excellent |
C/C | Cannot Comment/Don’t Know |
Using the scale above, how effective isthis doctor in: