Feedback Form Name PIH No Attending Doctor Mobile No Date Email ID Please tick if you consent to be on our mailing list YesNo I agree to publish my feedback on PIH Website or social media Please rate us on a scale of 1(lowest) to 5(highest) A. REGISTRATION 1 2 3 4 5 i) waiting time to reach counter (Registration/Billing/Counter) 12345 ii) Time taken by counter 12345 iii) Adequancy of information provided 12345 iv) Staff courtesy 12345 Overall Impression of Registration/Billing/Counter 12345 B. DOCTOR CONSULTATION 1 2 3 4 5 i) waiting time to see Doctor after completing registration/billing 12345 ii) Time spent by doctor 12345 iii) Information shared by Doctor about health and treatment options 12345 iv) Courtesy shown by Doctor 12345 Overall Impression of Clinical services 12345 C. NURSING 1 2 3 4 5 i) Technical expertise of Nurse 12345 ii) Response to queries by Nurse 12345 iii) Care offered during procedure or investigation by Nurse 12345 iv) Courtesy shown by Nurse 12345 Overall Impression of Nursing services 12345 D. PHARMACY 1 2 3 4 5 i) Waiting time to get medicines 12345 ii) Adequacy of Medicines available 12345 iii) Information shared by Pharmacist 12345 iv) Courtesy shown by Pharmacist 12345 Overall Impression of Pharmacy services 12345 E. GENERAL COMFORT 1 2 3 4 5 i) Cleanliness in waiting area 12345 ii) Cleanliness of toilets 12345 iii) Ease of finding way (directions) 12345 iv) safety and security arrangements 12345 Overall Impression of Housekeeping and Security services 12345 F. DIAGNOSTICS (Lab/ Radiology) 1 2 3 4 5 i) Waiting time for procedure 12345 ii) Information Provided by Nurse/ Technician (prepartion, results) 12345 iii) Efficiency of Nurse/ Technician performing the procedure 12345 iv) Staff courtesy 12345 Overall Impression of Diagnostic services 12345 Was this your first visit to PIH OPD as a Patient? YesNo How did you hear about us? Roadside / Event BillboardRadio AdvertisementFamily or FriendsTelephone DirectorySocial Media (Facebook, Twitter, Instagram)TV AdvertisementInternet SearchPhysician Referral Why did you choose PIH OPD Services (select all that apply)? PIH Doctor ReferralOutside Doctor ReferralHospital Brand and ReputationFriend/ Relative RecommendationConvenient LocationCorporate / Insurance Tie-upPast ExperienceOther If you are working in a company that does not have credit account with PIH, kindly share the name and contact details of the Human Resource coordinator: What did you like most about the Hospital? What did you not like about the Hospital? Would you like to name any particular staff who was very helpful, friendly or went out of the way to ensure a good healthcare experience? If you are unhappy with our services or with any staff, please provide us the name and instance for us to correct ourselves? On a scale of 1 to 5 how likely are you to recommend PIH to your family and friends? Any Comments/Suggestions:
