Homeopathy Patient Feedback Form

Invites patients of a homeopathic practice to rate the consultation, the premises, the medicine delivery service and the results they have noticed. Practitioners see what is working, which new services would appeal, and when each person prefers to be contacted again.

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Name

Nombre

Apellido

Phone number

How did you hear about us?

Friends or family Internet search Social media Referral from another practitioner Local advertising Walked past the clinic

What was your usual consultation format?

In person Video call Phone call Messaging or chat

How would you rate the atmosphere at the clinic?

Which complaints are you being treated for?

How long have you been in treatment?

Less than a month 1 to 3 months 3 to 6 months 6 to 12 months More than a year

Do you receive your medicines by courier from the clinic?

Yes, always Sometimes No, I collect them in person

Have you arranged a re-evaluation of your complaints?

Yes, already done Yes, it is scheduled Not yet I do not think I need one

Would you like the clinic to contact you about continuing treatment?

Yes, by phone Yes, by email Yes, by messaging app Not for now

Which upcoming services would interest you?

Nutrition counselling Online consultations Wellness workshops Home visits Paediatric clinic Chronic care plans

Share your suggestions for improving our service

What is the best time to reach you?

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