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Patient Satisfaction Survey & Follow Up Form
We want to be sure we are doing everything we can do to serve you. Please take a minute to fill out this confidential survey. Just let us know what we are doing well and what we can do better!
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* Indicates required question
ชื่อ - นามสกุล (Name-Surname)
*
Your answer
เพศ (Gender)
*
ชาย (Male)
หญิง (Female)
วัน เดือน ปีเกิด (Date of Birth)
*
MM
/
DD
/
YYYY
โทรศัพท์ (Phone number)
*
Your answer
อีเมล (Email)
Your answer
Who is the respondent?
Patient
Relative
Other:
Have the patient visit Jitta Life for the first time?
Yes
No
Clear selection
Why do you choose Jitta Life?
The reputation of treatment program and oncologist doctor
The reputation of services at Jitta Life
Apply modern technology and equipment/modalities
Reasonable price for medical expenses
Location and convenient transportation
Recommend by friends, relative
Other:
What is your symptom before having our treatment?
Your answer
How do you feel after having our treatment?
Your answer
What do you think for our service?
Your answer
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