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Patient feedback form

Patient feedback form

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Published by deenawants

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Published by: deenawants on Nov 26, 2010
Copyright:Attribution Non-commercial

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05/12/2014

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PATIENT FEEDBACK FORMOPD Date:……………As we strive to consistently improve our services of OPD, we seek your sincere feedback. Please help us by taking a few minutes to answer the following questions:How did you hear about us?Ad         Magazine       Friend        Family        Others(If others please specify) ………………………………………………Date of last visit:  …………………………………………(If you have visited earlier)Today, I had a prior  Appointment  Walk InDid you find our working hours convenient for you?Very Convenient  Convenient  Somewhat Convenient  Not ConvenientDid you find our parking convenient?Very Convenient  Convenient  Somewhat Convenient  Not ConvenientDid you feel convenient in identifying our department location?Very Convenient  Convenient  Somewhat Convenient  Not ConvenientUpon entering our department, were you properly greeted, and acknowledged by ourstaff?Excellent  Very Good  Good  Average  PoorDid the waiting area look clean, orderly and sufficient to sit?Excellent  Very Good  Good  Average  PoorDo you feel that you are waiting too long in our department?Yes        NoHow long did you wait before being seen by the Doctor?0 Mins.  5 Mins.  15 Mins.  30 Mins.  MoreWas the receptionist inside the department helpful, polite and pleasant?Excellent  Very Good  Good  Average  PoorWas the Doctor you are attending friendly, supportive and confident?Excellent  Very Good  Good  Average  PoorDid the Doctor explain your treatment, answer your questions, and listen to yourconcerns?Excellent  Very Good  Good  Average  PoorDid the Doctor room seem clean and hygienic?Excellent  Very Good  Good  Average  PoorReception, registration & Billing Counter StaffReception Excellent Good Satisfactory Poor Very PoorCourtesy    Competence    Knowledge & Skill   
 
 Time Management    Nursing StaffNursing Excellent Good Satisfactory Poor Very PoorCare & Concern    Knowledge & Skills    Clarity & Explanation    Other ServicesServices Excellent Good Satisfactory Poor Very Poor NeutralX-ray or Lab Services     Rehabilitation & Counseling     Pharmacy Services     Hospital Facilities & Equipment  

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