SuggestionComplaintsPraise

Hospital Visited	:
Ward/Department visited	:
Consulting Doctor	:
Date/Time	:

Do you feel comfortable returning to this health service in the future?
YesNo
Would you recommend this health service to a friend or relative?
YesNo
Your rating about the facilities :
ExcellentGoodAveragePoor
Your rating about the Staff:
ExcellentGoodAveragePoor

On a scale of 1 to 10, please select the number that describes your overall view of the service and care you received at our hospital (please select one number).
12345678910
Poor			Average			Excellent

Comments	:

Can you name one staff who excelled while serving you	:

Name
Telephone/Mobile no
Email Id
Address
Would you like a follow up feedback	YesNo