Patient Feedback Form

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Please fill this from to help us for improving patient service!

Help us to provide advanced and better health service.

Your feedback on hospital services is important to us in order to provide you with the best possible care and sincerity. It will be the moral responsibility of the hospital to keep your advice confidential and to make necessary improvements as per your suggestions. How much point will you give out of 5?

Patient / Relative Name *

First Middle Surname

Relation with patient *

Date of Admission *

MM/DD/YYYY

YYYY

Room No.

Name of Treating Doctor *

First Middle Surname

Rating on Admission Process *

Rating on Billing Process *

Nursing staff - their competence and behavior *

Medical Officer - their competence and behavior *

Rating on discharge process *

Rating about your treating doctor *

Rating about treatment and follow up *

Rating on housekeeping Services *

Room, Toilet, Bed Sheet etc

Medical service *

Pharmacy Service *

Overall your stay in the hospital *

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