Patient Registration Form

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PATIENT REGISTRATION FORM
Patient’s name			Date of registration
Gender		Male / female	Date of Birth
Guardian (In case of minor patient)			Relationship
Address			Mobile No:
			Landline No:
			Email ID
Occupation
Health Insurance available		Yes / No	Name of insurer
Referring doctor
FOR EMERGENCY SITUATION
Name of person to be contacted			Relationship
Contact No -1			Contact No. - 2
I state that all information provided above is correct. I understand the information is being collected to register me and enable me to access the services of this hospital.
Signature of patient / guardian			Date / Time

Patient Satisfaction Feedback Form

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PATIENT FEEDBACK FORM
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.
Date Of Admission		Date Of Discharge
Gender		Age
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)

No.	Questions	1	2	3	4	5	NA
Your satisfaction with our CLINICAL TREATMENT
1.	How satisfied are you with the outcome of your treatment?
2.	How satisfied are you with the competence of your doctor?
3.	How satisfied are you with the competence of other treatment staff (Resident doctor, nurses, therapists etc.)
Your satisfaction with our BEHAVIOUR towards you
4.	How satisfied are you with the behaviour of doctors towards you?
5.	How satisfied are you with the behaviour of nurses towards you?
6.	How satisfied are you with the behaviour of front office staff and customer care executives?
7.	How satisfied are you with the behaviour of other staff such as housekeeping and security?
Your satisfaction with our PROCESSES
8.	How satisfied are you with convenience of our admission process?
9.	How satisfied are you with convenience of our discharge process?
10.	How satisfied are you with provision of information to you?
11.	How satisfied are you with our patient safety processes?
12.	How satisfied are you with our other policies and process?
Your satisfaction with our SERVICES & FACILITIES
13.	How satisfied are you with the housekeeping and cleanliness?
14.	How satisfied are you with the maintenance of facilities?
15.	How satisfied are you with our security services?
16.	How satisfied are you with the comfort of your stay?
17.	How satisfied are you with the convenience of your visitors?
18.	How satisfied are you with the dietary services provided to you?
Your OVERALL satisfaction
19.	Please rate your overall satisfaction with the hospital
20.	Please indicate how likely are you to recommend our hospital to your friends and relatives for treatment Very likely Likely Can’t say Not likely Never
21.	Please write any other comments/feedback
Date of feedback: