PATIENT FEED BACK FORM

In order to improve quality assurance standards, it is important for a hospital like Indus to continually monitor its performance through patient feedback. Questionnaire, which appears on this page, is self-explanatory and has been prepared to evaluate different categories of Hospital services. Kindly spare few minutes of your time to fill-in your answers by marking in a box against each category which best reflects your opinion and have it mailed to the Hospital.

We wish you speedy recovery and the best that is available under the sun.

Administrator

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Please name the Hospital staff member who has impresed you most.

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Name
Designation
Positive Quality
Your Suggestions for Hospital, if Any

Date :
Please mark in the box if you wish your response to be kept confidential.

SERVICES
Excellent
Good
Fair
Poor
No Opinion
CLEANLINESS
Room
Toilet
Beds
RECEPTION & REGISTRATION
Courtesy
Promptness
Professionalism
TELEPHONE SERVICE
Service
FOOD SERVICE
Quality
Serving Time
Presentation
RADIO-DIAGNOSIS
&
ULTRASOUND STAFF
Courtesy
Promptness
Professionalism
LABORATORY STAFF
Courtesy
Promptness
Professionalism
PHARMACY STAFF
Courtesy
Promptness
Professionalism
NURSE AIDES
&
WARDS BOYS
Courtesy
Promptness
Professionalism
STAFF NURSES
Courtesy
Promptness
Professionalism
JUNIOR DOCTORS
Courtesy
Promptness
Professionalism
SENIOR DOCTORS
Courtesy
Promptness
Professionalism
The following information is optional:
Patient

First Name

Middle Name

Last Name
Address
Country Zip/Pin Code
Telephone No
Date :

 

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