Minor Surgery Questionnaire - Summerfield Healthcare

Your name*

Which procedure did we provide?*

Where was the lesion situated? e.g. back*

What was the reason(s) for surgery? e.g. cosmetic, irritation, pain*

Why did you book your procedure with Summerfield Healthcare? e.g. price, easy to find online, referral from friend*

Date of the procedure*

Location of procedure*

Name of GP or consultant seen*

Do you consent to Summerfield Healthcare using images of your procedure (if photos were taken) for our website and social media channels?*

Did the practitioner put you at ease prior to, and during the procedure?*

Did the practitioner give you a satisfactory explanation of the procedure and possible complications?*

Are you satisfied with how the surgical procedure was undertaken?*

Did you develop any complications?*

Do you consider that you had to travel far to attend our clinic?*

Would you recommend our services to your friends and family?*

Please provide any further comments

In a few words please describe your overall satisfaction with the procedure and your experience with Summerfield Healthcare*

Please print your name for signature purposes*

Today's date*