Patient Feedback Form
Please take a few moments to complete this form
Clinic Name
Unjani Clinic Botshabelo
Date
-
Month
-
Day
Year
Date
Age Group
Less than 20
21-30
31-50
51-60
60 upwards
Gender
Male
Female
N/A
Email
example@example.com
Overall satisfaction
Rows
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Value for Money
Nurse Patience
Quality of staff
Waiting Time
Hygiene
Waiting time
5 min
15 min
30 min
60 min
more than an Hour
Service you came for
Family planning
Consultation
Child Immunisation
Sonar
Covid Testing
Treatment
Other
Would you recommend your friends/family to Unjani Clinic Botshabelo?
Yes
No
Maybe
Where did you hear about Unjani Clinic Botshabelo?
By word of mouth
Flyer
Community Event
Mosupatsela FM
Passing by
Other
How can we improve our service. Any suggestions and/or complaints?
Save
Submit
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