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.