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IPD Patient Feedback Form

Name *

Contact Number *

Admission process

Behavior to staff *

5
4
3
2
1

Promptness *

5
4
3
2
1

Explanation of estimate *

5
4
3
2
1

Response *

5
4
3
2
1

Consultant/ Doctors

Counseling *

5
4
3
2
1

Treatment Process *

5
4
3
2
1

Nursing Services

Treatment Explanation *

5
4
3
2
1

Promptness and care *

5
4
3
2
1

Behavior of staff *

5
4
3
2
1

Room Comfort

Room facilities *

5
4
3
2
1

Comfort level *

5
4
3
2
1

Housekeeping

Cleanliness and unkeep *

5
4
3
2
1

Behavior of staff *

5
4
3
2
1

Radiology MRI, CT Scan, USG, X-Ray

Service on time *

5
4
3
2
1

Lab Services

Service on time *

5
4
3
2
1

Safety & Security

Behavior of staff *

5
4
3
2
1

Parking Services *

5
4
3
2
1

Dietary Services

Dietary Counseling *

5
4
3
2
1

Food & Beverages Services

Quality of food *

5
4
3
2
1

Service on time *

5
4
3
2
1

Discharge Process

Experience *

5
4
3
2
1

Billing

Billing Experience *

5
4
3
2
1

Counseling by Staff *

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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