CUSTOMER HMO FEEDBACK FORM
Date
-
Month
-
Day
Year
Date
Company Name
Surname - First Name - Other Names
Enrollee Name
*
Surname - First Name - Other Names
Telephone
*
Email
*
Organization
*
Enrollee ID
*
What is your assessment of our services?
*
Excellent
Very Good
Good
Fair
Poor
Were you attended to promptly?
*
Yes
No
How long did it take to resolve your issue?
*
2 Mins
5 Mins
10 Mins
15 Mins
More than 20 Mins
Are you in the know of how issue is being resolved?
*
Yes, I was carried along
No Communication
I was abanonded
What is the body language of the attending Officer?
*
Professional
Unprofessional
Friendly
Rude
Good Communicator
Can you give Alleanza HMO referral to others?
*
Yes
No
If No, Pease give reason
General comment/Suggestions
Submit
Should be Empty: