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IPD Patient Feedback Form
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Patient's Name
*
Your answer
Age/Sex
Your answer
UHID No.
Your answer
Your opinion about the
Excellent
Very good
Good
Satisfactory
Poor
front office/Reception Staff
Nursing care services
Doctor (s) and Medical Care Services
Lab & Imaging Services
Pharmacy Services
Food Services
Hospital Expenses
General cleanliness of the Hospital
cleanliness of the bathroom/toilet
Security Services
Excellent
Very good
Good
Satisfactory
Poor
front office/Reception Staff
Nursing care services
Doctor (s) and Medical Care Services
Lab & Imaging Services
Pharmacy Services
Food Services
Hospital Expenses
General cleanliness of the Hospital
cleanliness of the bathroom/toilet
Security Services
Clear selection
How did you choose the inpatient services in this hospital:-
Preferred consultant attached
Own past experience
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From website
References from another doctor
References from friends/relatives
From Just dial
How long did you have to wait for admission?
Less than 10 min
20 to 30 min
More than 4 hrs
Clear selection
How much time was taken for discharge work?
Less than 2 hrs.
2 to 4 hrs.
More than 4 hrs.
Clear selection
Would you recommend this hospital to your friends, neighbours and relatives for treatment?
Yes
No
Clear selection
Do you wish to appreciate any of our staff in particular, please specify his/her name wth reason?
Your answer
Do you have any complaint against any of our staff, please specify his/her name?
Your answer
Any other Suggestion/Comments for improving our services:
Your answer
Date
MM
/
DD
/
YYYY
Name/Relation
Your answer
Your Mobile No.
Your answer
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