Hospital Feedback Form

Feedback Form

Dear Patient / Relative / Visitor,

Your continuing suggestions & support help to make our Hospital a better organization. Kindly spare a few moments to complete the following, so that we can strive to fulfill your expectations. Please drop the completed Feedback Form in the collection box, placed at the OPD reception, or hand it over personally to Administrator – OPD / MS.

Warm Regards,

Director’s Office

FEEDBACK FORM

I came as a (Please Tick)          Patient                         Relative                        Visitor

NAME                                                 REG. NO.        AGE                            SEX M / F

ADDRESS                  

PHONE / EMAIL                                                                               DOCTOR

DIAGNOSIS                                                   TREATMENT

My hospital stay at VJEH was because of the following factors :

           Pleasant           Satisfactory    Unpleasant 

The Hospital environment is                                                    Good                Average           Poor 

The Toilet(s) are                                                                        Good                Average           Poor 

The service of attending Doctors is                                          Good                Average           Poor 

The service of attendant Nurses is                                            Good                Average           Poor 

The Hospital Billing is                                                               Good                Average           Poor 

The Reception / Enquiry service is                                           Good                Average           Poor 

The Admission Process is                                                          Good                Average           Poor 

The Discharge Process is                                                          Good                Average            Poor 

Were you satisfied with the care & procedure                          Good                Average            Poor 

Overall I rate VJEH as                                                              Good                Average            Poor

Would you prefer to recommend us to others?       Strongly     Most likely   Less likely    Never

Special Comments:

Thanks for giving your valuable time to fill up this form. We are committed in providing you with the best quality care possible.