CUSTOMER HOSPITAL FEEDBACK FORM

CUSTOMER HOSPITAL FEEDBACK FORM
Date

MonthDayYear
Date
Enrollee Name*
Surname - First Name - Other Names
Telephone*
Email*
Organization*
Enrollee ID*
Kindly indicate by ticking the circles for your rating
How satisfied are you with the service at the hospital?*

Very SatisfiedSatisfiedUnsatisfiedVery UnsatisfiedNot Applicable
Are the Hospital front desk officers friendly & courteous?*

Very friendlyFriendlyCasualUnfriendlyVery Unfriendly
How did the nurses attend you*

Very goodGoodFairBadWorse
What is your assessment of the doctor's consultation*

Very attentiveEmpatheticFriendlyHastyHarsh
Rate the hospital premises*

Very neatNeatFairly neatDirtyUnkept
Any other issues/Comments
Should be Empty: