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LifeLine Hospital::Customer Survey
Inpatient Feedback Form
Personal Information
Name
:
Email Address
:
Age
:
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Sex
:
Male
Female
Country
:
Phone Number
:
Please mark how well you think we are doing in the following areas
Ease of getting care:
Not Applicable
Poor
Good
Excellent
Ability to get in to be seen
Hours Hospital is open
Convenience of Hospital's location
Prompt return on calls
Waiting:
Not Applicable
Poor
Good
Excellent
Time in waiting room
Time in exam room
Waiting for tests to be performed
Waiting for test results
Reception, Customer care Staff:
Not Applicable
Poor
Good
Excellent
Friendly and helpful to you
Answers your questions
Physicians:
Not Applicable
Poor
Good
Excellent
Listens to you
Takes enough time with you
Explains what you want to know
Gives you good advice and treatment
Nurses and Medical Assistants:
Not Applicable
Poor
Good
Excellent
Friendly and helpful to you
Answers your questions
Payment:
Not Applicable
Poor
Good
Excellent
What you pay
Explanation of charges
Collection of payment/money
Facility:
Not Applicable
Poor
Good
Excellent
Valet Parking
Neat and clean building
Ease of finding where to go
Comfort and Safety while waiting
Privacy
Confidentiality:
Not Applicable
Poor
Good
Excellent
Keeping my personal information private
The likelihood of referring your friends and relatives to us
What do you like best about our Hospital?
What do you like least about our Hospital?
Suggestions for improvement?
