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We thank you for choosing our hospital for your treatment. We would like to know how much have we been able to
satisfy you, so that we can improve our services further. Please fill this feedback form and hand it in confidence to our
customer care executive.
We urge you to provide the most honest feedback. We have purposefully kept the form anonymous, and assure you
of full confidentiality of the data provided in this form. Thanks.
Date Of Date Of
Admission Discharge
Gender Age
Please rate following questions on a scale of 1 to 5 where, (Check the appropriate box)
5 – Highly Satisfied,
4 – Satisfied,
3 – Nether satisfied nor dissatisfied
2 – Dissatisfied
1 – Highly dissatisfied
NA – Not applicable (Or can’t answer)
No. Questions NA
1 2 3 4 5
A. Your satisfaction with our CLINICAL TREATMENT
1. How satisfied are you with the outcome of your treatment?
3. How satisfied are you with the competence of other treatment staff
(Resident doctor, nurses, therapists etc.)
5. How satisfied are you with the behaviour of nurses towards you?
Date of feedback: