Outpatient Satisfaction Survey Form
Dear Patient,
We hope that we have addressed your health concerns to the best of our abilities. As we strive to improve and upgrade our facilities, a few minutes of your valuable time in answering the questionnaire below will assist us in improving our services. Kindly tick the response which best suits your experience. So help us to help you. Thank you.
Please note that all information relates to the patient.

DBSH/QLTY/PFR/OSSF/1.20                    VER: 04                                  Effective date: 25/03/2021
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1. Please state the date of your visit *
MM
/
DD
/
YYYY
2. Name (optional)
3. Contact number (optional)
4. Was the appointment a? *
5. Please indicate the name of the doctor that you saw *
6. Age: *
7. Assess the registrations clerks, receptionist and cashiers skills on the mentioned scale? *
Exceeds expectations
Meets expectations
Unsatisfactory
Communication
Attentive While Listening
Helpful and Co-operative
Provides respectful care & personal diginity
Overall
8.  The waiting time for seeing the doctor was? *
9.  Asses the Doctors skills on the mentioned scale *
Exceeds expectations
Meets expectations
Unsatisfactory
Communication
Attentive While Listening
Helpful and Co-operative
Provides respectful care & personal dignity
Overall
10. Did you refuse the treatment advised by the doctor? *
11. To what extent did you receive clear and helpful information before you went home about the next step *
12. Would you return to this hospital if you needed medical care? *
13. How did you learn about Dr. Balwant Singh's Hospital Inc.? *
14. What can the hospital do to improve?
15. Please feel free to voice any other comments, suggestions and complaints faced by you that are not included in the questions above.
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