LGBRIMH

Patient/ Attendent Feedback Form

An asterisk ( * ) indicates a mandatory field.

Name of the Patient / Attendent *

Email *

Contact No.

Address

Subject *

Hospital Environment

Good Average Poor

Please Specify

Overall Cleanliness

Good Average Poor

Please Specify

Toilet Facilities

Good Average Poor

Please Specify

Drinking Water Facilities

Good Average Poor

Please Specify

Registration Facilities

Good Average Poor

Please Specify

Service of the attending doctor

Good Average Poor

Please Specify

Service of the Nurse

Good Average Poor

Please Specify

Service of other Staffs

Good Average Poor

Please Specify

Service of the allied branch i.e., CP/PSW

Good Average Poor

Please Specify

Service of the Pharmacy

Good Average Poor

Please Specify

Overall Experience

Good Average Poor

Please Specify

To help prevent automated spam, please answer this question

* Using only numbers, what is 8 plus 2?

Patient/ Attendent Feedback Form An asterisk ( * ) indicates a mandatory field.
Name of the Patient / Attendent *
Email *
Contact No.
Address
Subject *
Hospital Environment	Good Average Poor	Please Specify
Overall Cleanliness	Good Average Poor	Please Specify
Toilet Facilities	Good Average Poor	Please Specify
Drinking Water Facilities	Good Average Poor	Please Specify
Registration Facilities	Good Average Poor	Please Specify
Service of the attending doctor	Good Average Poor	Please Specify
Service of the Nurse	Good Average Poor	Please Specify
Service of other Staffs	Good Average Poor	Please Specify
Service of the allied branch i.e., CP/PSW	Good Average Poor	Please Specify
Service of the Pharmacy	Good Average Poor	Please Specify
Overall Experience	Good Average Poor	Please Specify
To help prevent automated spam, please answer this question * Using only numbers, what is 8 plus 2?