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IPD Patient Feedback Form
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Name
*
Contact Number
*
Admission process
Behavior to staff
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5
4
3
2
1
Promptness
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5
4
3
2
1
Explanation of estimate
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5
4
3
2
1
Response
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5
4
3
2
1
Consultant/ Doctors
Counseling
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5
4
3
2
1
Treatment Process
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5
4
3
2
1
Nursing Services
Treatment Explanation
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5
4
3
2
1
Promptness and care
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5
4
3
2
1
Behavior of staff
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5
4
3
2
1
Room Comfort
Room facilities
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5
4
3
2
1
Comfort level
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5
4
3
2
1
Housekeeping
Cleanliness and unkeep
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5
4
3
2
1
Behavior of staff
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5
4
3
2
1
Radiology MRI, CT Scan, USG, X-Ray
Service on time
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5
4
3
2
1
Lab Services
Service on time
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5
4
3
2
1
Safety & Security
Behavior of staff
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5
4
3
2
1
Parking Services
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5
4
3
2
1
Dietary Services
Dietary Counseling
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5
4
3
2
1
Food & Beverages Services
Quality of food
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5
4
3
2
1
Service on time
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5
4
3
2
1
Discharge Process
Experience
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5
4
3
2
1
Billing
Billing Experience
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5
4
3
2
1
Counseling by Staff
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5
4
3
2
1
Overall Experience
Satisfaction score
*
5
4
3
2
1
Would you recommend us to others?
*
Yes
No
Any Comment or suggestion
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