Address : 11 Coldharbour Lane, Hayes UB3 3EA
Telephone : 0208 813 7626

Patient Survey

This section is about why you visited the pharmacy today

Why did you visit this pharmacy today?

Someone else

For some other reason

If you collected a prescription today, were you able to collect it...

Straight away
Waited in pharmacy
Came back later

How satisfied were you with the time it took?

Not at all satisfied
Not very satisfied
Fairly satisfied
Very Satisfied

This section is about the pharmacy and the staff who work there more generally, not just for today's visit

Thinking about any previous visits as well as today's, how hould you rate the pharmacy on the following factors?

  • Very poor
  • Fairly poor
  • Fairly good
  • Very good
  • Don't know

a) The cleanliness of the pharmacy

b) The comfort and convenience of the waiting areas (e.g. seating or standing room)

c) Having in stock the medicines/appliances you need

d) Offering a clear and well organised layout

e) How long you have to wait to be served

f) Having somewhere available where you could speak without being overheard, if you wanted to

Again, including any previous visits to this pharmacy, how would you rate the pharmacist and the other staff who work there?

  • Very poor
  • Fairly poor
  • Fairly good
  • Very good
  • Don't know

a) Being polite and taking the time to listen to what you want

b) Answering any queries you may have

c) The service you received from the pharmacist

d) The service you received from the other pharmacy staff

e) Providing an efficient service

f) The staff overall

Thinking about all the times you have used this pharmacy, how well do you think it provides each of the following services?

  • Not at all well
  • Not very well
  • Fairly well
  • Very well
  • Never used

a) Providing advice on a current health problem or a longer term health condition

b) Providing general advice on leading a more healthy lifestyle

c) Disposing of medicines you no longer need

d) Providing advice on health services or information available elsewhere

Have you ever been given advice about any of the following by the pharmacist or pharmacy staff?

  • Yes
  • No

Stopping smoking

Healthy eating

Physical exercise

Which of the following best describes how you use this pharmacy?

This is the pharmacy that you choose to visit if possible
This is one of several pharmacies that you use when you need to
This pharmacy was just convenient for you today

Finally, taking everything into account - the staff, the shop and the service provided - how would you rate the pharmacy where you received this questionnaire?

  • Poor
  • Fair
  • Good
  • Very good
  • Excellent

If you have any comments about how the service from this pharmacy could be improved, please write them in here:

These last few questions are just to help us categorise your answers

How old are you?


Are you ...


Which of the following apply to you:

You have, or care for, children under 16
You are a carer for someone with a longstanding illness of infirmity

Thank you for completing this questionnaire

How to Register for your First Delivery

Simply fill out the form on the right.

How to Reorder

Reorder by Freephone, email or Freepost using the contact details below.


Call 0208 813 7626 to let our staff know what you need, then forward your prescription (Freepost envelopes available) to your local care centre.


Send an email to then forward your prescription to your care centre.