Constantia Patient Feedback Form

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ONLY SUBMIT THIS FORM ONCE YOU HAVE COMPLETED YOUR SERIES OF INFUSIONS.

Thank you allowing us to offer you our specialised infusion service and thank you for trusting us with your care. Your feedback is very important to us at KCSA, as we strive to constantly improve our service.

Your comments may well benefit others using our service in future and we would be grateful if you would take a moment of your time to complete this questionnaire.

    Date

    1. Compared with how you felt before you started your series of infusions, how much of a positive difference has the treatment made?

    a. No difference at allb. Some differencec. A significant differenced. A huge difference

    2. Which of the following best describes your expectation of the treatment and outcome?

    a. The outcome of the treatment is well below my expectationb. The outcome of the treatment is what I expectedc. The outcome of the treatment exceeded my expectation

    3. Would you describe your infusions as the most effective treatment you have tried for your condition?

    a. Yesb. No

    4. Did you feel safe in the hands of the physician and staff administering your infusions?

    a. Not at allb. Somewhatc. Completely

    5. Please describe in your own words the effect your infusions have had on your life.

    6. Is there anything you didn’t like about your infusion therapy experience? Please tell us below

    7. Do you have any suggestions that might help us improve the experience of others in the future?

    8. Should you wish, please ask a close member of your family to write down what difference they have witnessed in you since your infusions. (They should indicate their relationship to you.)