Feedback Form

Dear Patient / Relative / Visitor,

We are grateful to you for giving us the opportunity to serve you. To help us in our endeavor to serve you better we sincerely request you to give us your opinion and suggestions. Your identity will remain confidential. We appreciate your feedback and assure you of our best services always.


Patient Name (required)

Age (required)

Doctor Name

Phone No

1. The Reception / Enquiry service is

2. The service of attending Doctors is

3. The Hospital environment is

4. The Toilet(s) are

5. The Food / Diet are

6. The service of attendant Nurses is

7. The Admission Process is

8. The Discharge Process is

9. The Hospital Billing is

10. The Ward Facilities are

11. As an appreciation to our staff member, please feel free to mention any staffs who has taken good care of you during your stay at the hospital

12. Would you prefer to recommend us to others
StronglyMost likelyLess likelyNever

13. Complaint for any of staff

Describe the act due to which you have this kind of impression
Name :
Designation :
Type Text :

Any suggestion for improvement

Thank you for giving your valuable time to fill up this form. We are committed in providing you with the best quality care possible. Part of this commitment is to understand – Where we are exactly


We wish you Good Health, Peace and Happiness