Patient Feedback - Outpatient Services

Name

Age

Sex

Male Female

Category of Patient

Unit/Department

Name of the Doctor(Optional)

Why did you choose to come to CMC Hospital for treatment
	Recommended by others Previous experience in CMC Referred by a Doctor Good Reputation Any other reason? (Please specify)

How did you book your appointment?

Telephone Email Online In - person Others

Booking Date		Appointment Date
Phone Number		Email ID

Please rate the following staff in the Outpatient Department of CMC
	Excellent	Good	Satisfactory	Poor	V.Poor
Reception Staff
Registration/ Booking counter Staff
Triage/ New Registration Staff
Medical Records Officers (MRO)
Doctors
Nurses
X- Ray Technicians
Blood Collection Technicians
Pharmacy Staff
Security Staff
Administrators

Please rate the following services
	Excellent	Good	Satisfactory	Poor	V.Poor
Reception and guidance
Registration system
Triage/ New Registration services
Medical services by the Doctors
Nursing Services
X-Ray Services
Blood Collection Area
Pharmacy services
Security Department

Please rate the following facilities
	Excellent	Good	Satisfactory	Poor	V.Poor
Seating arrangements
Drinking Water
Toilets
Wheelchairs and Stretchers
Lifts
Signboards and signposts
Cafeteria

Based on your current experience, would you recommend this hospital to your Family/Friends?

Strongly recommend Likely to recommend Unlikely to recommend Will not recommend Neutral

Do you wish to Compliment any staff for outstanding care and services?

Please share your experience at the hospital with us and any Suggestions on how we can further improve our services.