FEEDBACK Feedback Form PATIENT INFORMATION I am a * Patient Attender Visitor Name of the Patient * Contact Number * Email Id Visit Date Room Number (If you are an in-patient) FEEDBACK SURVEY Reception (Guidance & Response to queries) Poor Satisfactory Good Very Good Excellent Treatment by Physicians / Consultants Poor Satisfactory Good Very Good Excellent Pharmacy Poor Satisfactory Good Very Good Excellent Nursing Staff Care (Attitude & Promptness) Poor Satisfactory Good Very Good Excellent Billing (Response to queries & Promptness) Poor Satisfactory Good Very Good Excellent Cleaning & Hygiene Poor Satisfactory Good Very Good Excellent Overall Courtesy Poor Satisfactory Good Very Good Excellent Name of Staff Any Other Remarks Reason Please rate your experience at Supreme Specialty Hospitals * Excellent Good OK Need to Improve
