FEEDBACK FORM Dear Sir / Mam,
Vaatsalya Group of Hospitals strives to deliver Care with and to follow ‘Ethical Practice’. We
appreciate the time taken to complete this form and truly value your suggestions that we hope will enable us to provide the highest quality patient care. Name : ....................................................
MRN No: ...............................
Contact Number : .....................................
Email ID: ................................
Treating Doctor: ........................................
Date : ....................................
Is this your first time visit to this Hospital?
Yes
No
Why did you choose the Hospital: ........................................................................ Doctor’s Recommendation : ......................
Insurance Requirement : ..................
Friends or Relatives Recommendation : ......................
Location : .......................................
Reputation of the Hospital
Others : .........................................
Excellent
Good
Average
Should Improve
1. REGISTRATION - How would you rate each of the following ? i. External Access to the Hospital ? ii. Telephone Information ? iii. Greeting on Arrival ? iv.Promptness of appointment ? v.How would you rate the behaviour of the Reception staff ? 2. RECEPTION i. How well were guided about which doctor to meet ? ii. How would you rate the Registration process ? iii. Doctor waiting time ? 15 min 25 min 30 min 45 min < 45 min 3. DOCTOR i.How clear was the doctors explanation on the ailment ? ii.How would you rate the Doctor ? 4.How would you rate each of the following ? i.Directions given by the staff ? ii.Internal Signages could guide you to the departments ? iii.How well did the staff answer all your questions ? 5. CLEANLINESS i.How would you rate the cleanliness of Toilets ? ii.How would you rate the behaviour of the Housekeeping staff ? iii.How would you rate the overall cleanliness of the hospital ?
No comments