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PATIENT FEEDBACK FORM
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We thank you for choosing our hospital for your treatment. We would like to know how much have we been able to satisfy you so that we can improve our services further. Please fill out this feedback form and hand it in confidence to our customer care executive.
We urge you to provide the most honest feedback. We have purposefully kept the form anonymous, and assure you of full confidentiality of the data provided in this form.
Thanks.
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Date Of Admission
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Date Of Discharge
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Gender
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Age
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Please rate following questions on a scale of 1 to 5 where, (Check the appropriate box)
5 – Highly Satisfied,
4 – Satisfied,
3 – Nether satisfied nor dissatisfied
2 – Dissatisfied
1 – Highly dissatisfied
NA – Not applicable (Or can’t answer)
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No.
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Questions
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1
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2
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3
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4
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5
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NA
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1.
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How satisfied are you with the outcome of your treatment?
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2.
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How satisfied are you with the competence of your doctor?
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3.
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How satisfied are you with the competence of other treatment staff (Resident doctor, nurses, therapists etc.)
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4.
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How satisfied are you with the behaviour of doctors towards you?
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5.
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How satisfied are you with the behaviour of nurses towards you?
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6.
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How satisfied are you with the behaviour of front office staff and customer care executives?
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7.
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How satisfied are you with the behaviour of other staff such as housekeeping and security?
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8.
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How satisfied are you with convenience of our admission process?
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9.
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How satisfied are you with convenience of our discharge process?
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10.
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How satisfied are you with provision of information to you?
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11.
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How satisfied are you with our patient safety processes?
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12.
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How satisfied are you with our other policies and process?
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13.
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How satisfied are you with the housekeeping and cleanliness?
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14.
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How satisfied are you with the maintenance of facilities?
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15.
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How satisfied are you with our security services?
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16.
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How satisfied are you with the comfort of your stay?
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17.
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How satisfied are you with the convenience of your visitors?
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18.
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How satisfied are you with the dietary services provided to you?
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19.
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Please rate your overall satisfaction with the hospital
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20.
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Please indicate how likely are you to recommend our hospital to your friends and relatives for treatment
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21.
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Please write any other comments/feedback
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Date of feedback:
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