CUSTOMER FEEDBACK FORM

Date: ____________________
We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your
responses are directly responsible for improving these services. Thank you for your time.

Patient Name: ______________________________ M.R. No.: ____________ Department: ________________

Attendant Name: ____________________________ Email: __________________________________________
Contact No.: ____________________ Address: ___________________________________________________
Great
5

Good
4

Ok
3

Fair
2

Poor
1

Not Sure
0

Time in waiting for examination by doctor

Waiting for lab tests to be performed & their results

Waiting for x-ray & ultrasound

Doctor discharge order and discharge from hospital

STAFF:

Receptionist listened & guided you properly

Nurses answered your questions and guided you adequately

Security staff dealt you respectfully

Physician listened and visited you regularly

Physician answered your queries properly & gave advice

BILLING:

Waiting for Completion of billing process

Explanation of charges during billing process

FACILITIES:

Neat and clean environment (Room, Wards & Wash Rooms)

Ease of finding where to go within the hospital

Privacy, Comfort and Safety during your stay at hospital

Convenience of Hospital location, Parking & Transportation

Condition of furniture in waiting areas / wards

MISCELLANEOUS:

The likelihood of referring your friends and relatives to us

Overall rating of the Hospital

Please circle how well our services are:

WAITING:

Does hospital staff ask for Tip/ Money from you?

If yes kindly mention his/her name:

Yes

No

Suggestions & comments: ____________________________________________________________________________

___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________ Signature:

QA0 01/181012

Thank you for your feedback!

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