CARE AND SERVICES FEEDBACK

We trust that your experience with Mildura Health Private Consulting has been to your satisfaction.

We would appreciate you completing this short survey to assist us in improving the service we provide.

This survey should take around 5-10 minutes to complete.

Date of visit *

Please rate each statement

Comments

Please rate each statement

Please rate each statement

Comments

Please rate each statement

Comments

Please rate each statement

Comments

Please rate each statement

Comments

Please rate each statement

Comments

If you could suggest one area of improvement for our practice, what would it be?

Do you identify as Aboriginal or Torres Strait Islander? *

Do you have any of the following concession cards? *

Health Care CardPensioner Concession CardVeteran Health Care CardNone of the above

Tick all that apply

Other than English, what other language/s do you speak at home?If applicable

Would you like to be contacted to discuss your comments further? *

YesNo

Name *Patient / Parent / Family / Friend / Carer

Telephone *

Would you be happy to be contacted by hospital / consulting room staff to take part in further service evaluation? *

YesNo

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