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MORYING CLINIC - Patient Satisfaction Survey
MOR YING CLINIC
489, 489/1, 489/3 Moo 1, T. Mae Hia, A. Muang, Chiang Mai 50100
Tel : +66 93 134 5078, +66 62 939 5635
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* Indicates required question
Name - Surname
Your answer
1) You’re
*
Patient
Patient’s relative
2) Gender
*
Male
Female
3) Age
*
<30
31-40
41-50
51-60
>60
4) Contact
*
*Email, Telephone
Your answer
5) Address
*
Your answer
6) Country
*
Your answer
7) Medical coverage
*
(Choose one or more)
Self payment
Private Insurance
Third Party
Compulsory Insurance
Government Insurance
Provident Fund
Social Security Insurance
Others :
Other:
8) Service Department
*
(Choose one or more)
Beauty
Body
Wellness
Others :
Other:
9) Please rank your satisfaction level of service from MOR YING CLINIC
Least
1
2
3
4
5
6
7
8
9
10
Most
Clear selection
10) Will you recommend MOR YING CLINIC ?
Least
1
2
3
4
5
6
7
8
9
10
Most
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11) Staff or Department that you were impressed.
Your answer
12) Please tell us about your impressive event.
Your answer
13) How did you hear about us?
(Choose one or more)
Word-of-mouth
Search Engine eg. Google
Website
Social media
Newspaper/Magazine
Events
Agency
Others :
Other:
Clear selection
14) Overall Services
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.1 Customer service
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.2 Doctors
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.3 Nurses
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
worst
1
2
3
4
5
Excellent
Clear selection
14.4 Pharmacy
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.5 Rehabilitation
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.6 Cashier
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.7 Environment
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.8 Cleaness
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
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14.9 Hygine and Disinfection
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.10 Security
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.11 Rest rooms
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.12 Disable Facilities
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
14.13 Transportation
Service - Excellent (5), Good (4), Normal (3), Bad (20), Worst (1)
Worst
1
2
3
4
5
Excellent
Clear selection
15) Your recommendation
Your answer
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