Amarleela.Com
Amarleela.Com
TI
SO
RNA
MA
feedback
Full Name: Gender:
Male
Female
Referred by: Date of Birth:  
IPD Number: Admission Date:  
Room No./Type: Discharge Date:  
Please help us to review and improvise our services. Your feedback is very valuable for our Quality Inspection and Control Process and shall be kept completely confidential. Thank You, Management Amarleela Hospital.
Please Rate Using Numbers
Excellent - 8
Good – 6
Improve - 5
Bad – 3
S.No.
Please Rate Your Experience
Efficiency
Clarity
Paperwork
Remarks
A
Processes        

1

The Admission Process        

2

The Initial Diagnosis by the Resident Doctor

       

3

Information on Choice of Rooms and an estimate of your treatment

       

4

Information on Different Packages

       

5

Information on Visitor Policy

       

6

Health Insurance Approval

       

7

The Billing/ Check Out

       
B

The Infrastructure

Location

Clean/ Fresh

Noise

Remarks

1

The Reception

       

2

The ICU/Nursery

       

3

The Room and Its Infrastructure

       

4

The Waiting Lounge

       

5

Public / Toilets

       

6

The Chemist Shop

       

C

Name the Best Staff for

Appearance

Courtesy

Knowledge

Helpfulness

1

Resident Doctor

       

2

Staff Nurse

       

3

Cleaning Staff/ Ward Boy/ Ayaah

       

4

Maintenance/ Services

       

D

Name the Staff who needs Improvement

Appearance

Courtesy

Knowledge

Helpfulness

1

Resident Doctor

       

2

Staff Nurse

       

3

Cleaning Staff / Ward Boy/ Ayaah

       

4

Maintenance/ Services

       

E

Overall Experience at Amarleela

Very Satisfied

Satisfied

Unsatisfied

Traumatic

1

Will you come back to Amarleela

For Sure

Maybe

No

Never

2

Will you recommend Amarleela Hospital to Others

For Sure

Maybe

No

Never

3

Family/Friend who needs medical services?

Name

 

Number

 

4

Do you have Medical Insurance?

Name

 

Amount

 
Remarks if Any:
SUBMIT          CANCEL
Amarleela.Com
 
|
|
@ 2012 Amarleela Hospital Pvt. Ltd. All Rights Reserved