Dear Customer, Thank you for choosing Our services.Our commitment is to offer services that meet the highest healthcare standards.We hope that we have been able to measure up to your expectations. Please spare a few moments to fill in this form.Your valuable feedback will enable us to serve you better. |
Please share any comment's to improve us: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ |
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How do you rate our staff and services? | Please describe if any members Of our staff impressed you: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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Rating's: | Excellent | Good | Average | Poor |
Services availed: Consultation Diagnostics Pharmacy Health Check-Up Physiotherapy Any Other_______________________ |
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Email: __________________________________________________ |
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Courtesy and help offered: | PID No:__________________ Age:________________ | ||||
Speed of service delivery: |
Name: __________________________________________________ |
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Doctor's courtesy and interaction: |
Address: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ |
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Cleanliness within the clinic: |
Phone Number: _____________(Res.) _____________(Off.) |
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Layout and design of the clinic: |
What additional service(s) would you like which are presently not available: Dentistry Endoscopy Day Care Unit Maternity Center IVF(Fertility Clinic) MRI CT Scan Any Other_____________________ |
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Would you come to this clinic For your future health care need's: Yes No |
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How did you know about the clinic: AdvertisementPaper Insert's TOI HT NBT Banners ________________ _________________ |
If no, comment on reason for dissatisfaction:
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__________________________ Signature & Date thank you for your time. |