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CUSTOMER SURVEY FEEDBACK FORM
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Good day, please select the service that you would like to rate
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Admission
Appointment Booking
Billing/Cashier
Discharge
Food and Beverage
Housekeeping
Inpatient Wards
Laboratory
Outpatient Clinics
Pharmacy
Physiotherapy
Registration
X-ray
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Please select the clinic that you would like to rate
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Accidents & Emergency
Blood Donor
Cosmetic & Reconstructive
Daycare (Oncology)
Dental
Dermatology
Ear, Nose and Throat (ENT)
Eye Clinic
Endocrinology
Gastroenterology
Heart Centre
Internal Medicine
Nuclear Medicine
Neuro-Behavioral
Neurology
Neurosurgery
Obstetrics and Gynaecology (OBGYN)
Orthopedic
Oncology
Paediatric
Radiotherapy
Renal
Surgical
Urology
Wellness Centre
Wound Care
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Please select the ward that you would like to rate
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Daycare (Dermatology)
Daycare (Endoscopy)
Daycare / Recovery
Intensive Care Unit (ICU)
Maternity
Medical 1A (Room 501-518)
Medical 1B (Room 519-529)
Medical 2 (Room 226-236)
Medical 3 (Room 204-224)
Medical 5 (Room 601-621)
Neonatal Intensive Care Unit (NICU)
Paediatrics
Surgical 1 (Room 401-416)
Surgical 2 (Room 255-275)
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Which F&B section would you like to rate
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Inpatient Wards
Cafeteria
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Which Physiotherapy unit would you like to rate
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Inpatient Physio
Outpatient Physio
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Which Housekeeping section would you like to rate
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Inpatient Wards
Outpatient
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Please rate your overall satisfaction with the service
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1
2
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4
5
Which aspect(s) do you rate as above? You may select 1 or more options.
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Staff’s politeness, courteousness and helpfulness
Clear instructions on medications and procedures
Medical assistance provided
Waiting time for consultation
Doctor's explanation
Doctor's treatment plan
Did the staff check on your name and date of birth?
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Yes
No
Were you given a proper follow-up instructions if your condition/sickness worsened?
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Yes
No
Comments and Feedbacks
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Please rate your overall satisfaction with the service
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2
3
4
5
Which aspect(s) do you rate as above? You may select 1 or more options.
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Staff’s politeness, courteousness and helpfulness
Clear instructions on medications and procedures
Chaplain's visit
Doctor's explanation
Doctor's treatment plan
Did the staff check on your name and date of birth?
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Yes
No
Did the nurse ask whether you have any allergies before serving medication?
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Yes
No
Did the nurse check on your condition during ward rounds?
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Yes
No
Were you given a proper follow-up instructions if your condition/sickness worsened?
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Yes
No
Comments and Feedbacks
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Please rate your overall satisfaction with the service
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1
2
3
4
5
Which aspect(s) do you rate as above? You may select 1 or more options.
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Staff’s politeness, courteousness and helpfulness
Clear instructions on medications and procedures
Did the staff check on your name and date of birth?
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Yes
No
Comments and Feedbacks
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Next
Please rate your overall satisfaction with the service
*
1
2
3
4
5
Which aspect(s) do you rate as above? You may select 1 or more options.
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Staff’s politeness, courteousness and helpfulness
Clear instructions on procedures
Waiting time
Comments and Feedbacks
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Please rate your overall discharge experience
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1
2
3
4
5
Comments and Feedbacks
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Please rate your overall satisfaction with the Wards Meal service
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4
5
Which aspect(s) do you rate as above? You may select 1 or more options.
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Staff’s politeness, courteousness and helpfulness
Food Quality
Taste
Served on time
Comments and Feedbacks
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Please rate your overall satisfaction with the Cafeteria meal service
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1
2
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4
5
Which aspect(s) do you rate as above? You may select 1 or more options.
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Staff’s politeness, courteousness and helpfulness
Food Quality
Taste
Comments and Feedbacks
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Please rate your overall satisfaction with the service
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1
2
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5
Which aspect(s) do you rate as above? You may select 1 or more options.
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Staff’s politeness, courteousness and helpfulness
Cleanliness
Room facilities
Washroom
Comments and Feedbacks
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Please rate your overall satisfaction with the service
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2
3
4
5
Which aspect(s) do you rate as above? You may select 1 or more options.
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Staff’s politeness, courteousness and helpfulness
Cleanliness
Facilities
Comments and Feedbacks
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How satisfied are you with the method of booking?
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How did you book your appointment?
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Scheduled by phone
Through PAH Mobile App
Walked in
Did you receive reminder for each of your appointment?
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Yes
No
Were you updated when delay are anticipated?
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Yes
No
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How was your overall experience at the hospital?
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Considering your complete experience with our hospital, would you recommend us to your family, friend or colleague?
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Yes
No
Name
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Phone Number
MRN / Hospital Number
Email
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