Clone of Client Feedback Form

Clone of Client Feedback Form

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  • Client Feedback Form

    WE VALUE YOUR OPINION
  • We constantly look for ways to improve our services to you. By answering this survey, you will help us make that goal possible.

    Kindly fill out this form completely and submit at the reception area.

  • In order for us to clarify certain comments, may we request that you fill out the following information. We assure you that your personal information and answers to this survey will be treated with confidentiality.

  •  -
  • Please check the appropriate rating:

    (5) Excellent - exceeds expectations at all times

    (4) Very Good - exceeds expectations most of the time

    (3) Good - meets expectations all the time

    (2) Fair - meets expectations sometimes

    (1) Needs Improvement – rarely meets expectations

    N/A – Not applicable

  •   1 2 3 4 5 N/A
    1. Statement of Account presented was accurate
    2. Payment method is convenient
    3. Billing processing time
  •   1 2 3 4 5 N/A
    1. Time spent for consultation
    2. Physician clearly explained my health care plans, test/treatments and prescription
    3. Physician gave necessary instruction after consultation
    4. Physician was friendly , courteous and caring
  •   1 2 3 4 5 N/A
    1.Staff were friendly, well groomed and accommodating
    2. I was given a brief explanation of my appointment today
    3. I was necessary and clear instructions after my consultation
    4. My appointment was very well coordinated among the healthcare team members
    5. My Health Manager kept in close coordination with me during my time away from the Center
  •   1 2 3 4 5 N/A
    1. The Center and the consultation room were clean and cozy
    2. Furniture and fixtures were in good condition
    3. Equipment used during my visit was fully functioning
    4. Availability of beverages and refreshments
  •   1 2 3 4 5 N/A
    1. Overall care and experience
    2. Staff professionalism
    3. Value for money
    4. Appointment scheduling and time spent at the Center

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