FEEDBACK FORM

પપપપ

Name of Patient/ :__________________________________________________________

Consultant’s Name/પપપપપપ પપપપપ

પપપપપપ:________________________________________________

Age/ પપપ :_______ Sex/પપપપ: ___________Room/ પ:____________ Date/પપપપપપ:____________

Rating:
A= Excellent/પપપપ પપપપપપપપપ
B= Good/ પપપપપપપપપ

C= Average/પપપપ પ
D= Poor/ પપપપપપપપપપ.

Reception : પ પપપપ/પપપ:
A
B
C
D

Handling of queries and guidance:

Handling and explaination of admission process:

પપપપ પપપ પપપપપપપપપપપપપપપ પ પપ પપપપપપ પપપપપપપપપપપપપ :

Promptness in completing the admission process:

પપપપ પપ પપપપપપપપપ પપપ પપ પપપ પપ .:

Promptness in handling the insurance/corporate related process:

પપપપ પપપપપપપપ પપપપપપ પપપ પપ પપપ :

Medical Staff/ પપપપપ પપપપપપ:

Medical officer’s explanation and answering queries related to patient’s disease in an understandable manner:
પપપપ પપપપ પપપપપપ પપ પપપ પ પપપ

પપપપપપ પપપપપપ પપપ પપપપ પપ પપપપપ પપપપપપપપ

Behavior and attitude of treating Doctor.

પપપપપપ પપપપપ પપપપપ પપ પપપપપ પપપપપપપપપપપ :

Behavior and attitude of nursing staff:

પપપપપપપપપપપપ પપપપપ પપપપપપપપપપપ :

Prompt response by nursing staff:

પપપપપપપ પપપ પપપ પપ પપપ પપપપપપ પપપપપ .

Quality of nursing care provided:

પપ પપપપ પ

SUPPORT SERVICES:

Behavior & attitude of staff providing food and baverages:

પપપપપ પપપપપ પપ પપપપપ પપપપપપપપપપપ :

Timeliness of food services:

પપપપપ પપપપપ પપ પપપ પપ:

Quality and quantity of food served:

Quality of linen and uniform:

Behavior and attitude of housekeeping staff:

પપપપ પપપપપપપપ પપ પપપપપ પપપપપપપપપપપ :

Overall cleanliness of the room:

પપપપ પ પપ પ પપપ:

CONSULTANT/ પ પ પ પ

Consultant’s explanation regarding disease and treatment:

પપ પપપપપ પપપપપપપપપ પ પપપપપપપપપપપપપપ પપપપપપ :

Consultant’s explanation regarding post discharge care & follow up:

પ પ પપપ પપપપપપપપપપપ પપ પપ પપપપપપ પપપપપપ :

BILLING/ પપપ પપ પપપપ :

Behavior and attitude of billing staff:

પપપ પપ પપપપપ :

Promptness in handling of billing queries:

પપ પપપપપપપપપ પપ પપપ :

Timeliness on completion of billing process:

પપપ પ પપપપપપપ પપપપપપપપપ :

Other Suggestions or remarks to improve the services :

પ પ પપપપ પપપપ પપપપપ:

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પપપ પપપપ:_________________________ E- Mail :__________________________

THANK YOU FOR YOUR VALUABLE FEEDBACK