2 – Patient Feedback Form

FEEDBACK FORM

1.

Ref. No.

Ref/FDB/2022/

2.

Date of Feedback

Date of Discharge

3.

Name of Patient

4.

Hospital Membership

OP /GE / IP Numbers

5.

Consultant Incharge

Panel Name

6.

	Name of Service	Value
a.	The Service Rendered by the Front desk / Reception
b.	The Service Rendered by the pathlogy
c.	The Service Rendered by the X-Ray
d.	The Service Rendered by the USG
e.	The Service Rendered by the CT Scan
f.	Pharmacy
g.	Treatment carried by our Consultant
h.	The Service provided by our Resident Doctors (RMOs)
i.	The Service provided by our male / Female Nursing Staff
j.	The Service provided by our Housekeeping Staff
k.	The Service of canteen (Patient Food Service)
l.	The Cleanliness & maintenance of the Institute
m.	The Overall Experaince with Star Hospital
n.	Building Indratructure
o.	Treatment Cost

7.

Comments ; suggestions / Grivances

Submitted by:
Name
Contact No.
E-mail ID